PACEMAKERS AND ICD

Question 0

WHAT DOES A PACEMAKER DO?

Answer 0

TAKES OVER IF SA NODE FAILS…..CAN ONLY SPEED UP THE HEART. IT SENSES AND PACES.

Question 1

WHAT IS THE PACEMAKER OF THE HEART? WHAT OTHER NODE IS CAPABLE OF SPONTANEOUS DEPOLARIZATIONS?

Answer 1

SA NODE RATE 60-80 IMPULSES PER MIN.

AV NODE AT SLOWER RATE. PROTECTS VENTRICLES FROM EXCESSIVE ATRIAL BEATS.

Question 2

WHAT IS THE ANATOMY OF A PACEMAKER?

Answer 2

GENERATOR=BRAIN….HAS BATTERY THAT LASTS AROUND 10 YRS. SENSES AND FILTERS EKG.
LEADS=CONDUCT ELECTRICAL SIGNALS TO AND FROM THE HEART. UNI/BI POLAR. (BIPOLAR BOTH LEADS IN HEART AND LESS LIKELY TO PICK UP NON CARDIAC SIGNAL.
ELECTRODES: PORTION OF LEADS IN CONTACT WITH THE HEART. IMPULSE FROM HEART IS CONDUCTED AND MEASURED HERE. ALSO TRANSMITS ENERGY TO HEART.

Question 3

WHAT IS A TEMPORARY PACEMAKER? WHY IS IT USED?

Answer 3

HAS EXTERNAL PULSE GENERATOR. FOR ACUTE EVENTS UNTIL SURGERY, PERM PACER, OR ACUTE EVENT RESOLVES.
CAN BE NON INVASIVE: TRANSCUTANEOUS OR ESOPHAGEAL.
OR INVASIVE: TRANSVENOUS

Question 4

WHAT IS A PERMANENT PACEMAKER?

Answer 4

HAS INTERNAL PULSE GENERATOR WITH ENDO/EPICARDIAL LEADS WITH ELECTRODES IN OR ON HEART.

Question 5

WHY IS ADAPTIVE RATE PACING ADVANTAGEOUS?

Answer 5

ITS MORE SOPHISTICATED SO IT CAN DETERMINE SLEEP/EXERCISE AND IMPROVE QUALITY OF LIFE.

Question 6

WHAT DOES THE FIRST, SECOND, THIRD LETTER MEAN IN PACEMAKER CODE?

Answer 6

1- WHAT CHAMBER IS PACED. AVD
2- WHAT CHAMBER IS SENSED. AVDO
3- RESPONSE OF GENERATOR. AVDO

Question 7

WHAT IS DDD?

Answer 7

DUAL CHAMBER (AV) PACE AND SENSE THAT CAN EITHER PACE OR INHIBIT. IN THE EVENT OF NO INTRINSIC ACTIVITY- BOTH CHAMBERS ARE PACED AT PROGRAMED BASE RATE.

Question 8

WHAT DOES 3RD LETTER I MEAN?

Answer 8

THAT THE ONLY RESPONSE TO A SENSED EVENT IS INHIBITION…..IT DOES NOT PACE TO A SENSED EVENT….IT AVOIDS PACING ON THE T OR P WAVE.

Question 9

WHAT ARE OR PACER MODES? (ELECTROCAUTERY)

AND WHAT HAPPENS IN THIS MODE IF THE HR IS FASTER THAN THE INTRINSIC PACE SETTING?

Answer 9

VOO AND DOO. NO SENSE, NO INHIBITION! IT JUST PACES.

IF THE HR IS FASTER THAN PACER DEFAULT IT MAY PACE ON A P WAVE AND PT MAY GO INTO VF/VTACH.

Question 10

WHAT DOES AN ICD DO?

Answer 10

THEY PACE, SENSE, AND DEFIBRILATE. IT CAN SLOW THE HEART BY COUNTING HR/ CANT DISCRIMINATE RHYTHM.
IT ALSO HAS THE CAPABILITY OF PACING IF HR DROPS.

Question 11

WHAT ARE EXAMPLES OF EMI (ELECROMAGNETIC INTERFERENCE)
WHY IS THIS A PROBLEM?
WHEN IS IT LIKELY?

Answer 11

• EVERYTHING IN OR…CAUTERY IS BIGGIE. BUT WARMING BLANKET FASCICULATIONS, PNS, TOO.
• NOISE MAY GET TO GENERATOR AND THINK ITS CARDIAC AND WITHHOLD NEEDED PACE IMPULSES OR UNNECESSARILY SHOCK!
• LIKELY WHEN NOISE 50-100 HZ. CURRENT ABOVE UMBILICUS OR WITHIN 15 CM OF GENGERATOR.

Question 12

DOES CAUTERY INTERFERE WITH THE PACING MODE OF ICD’S?

Answer 12

NO! IT SEES SUSTAINED CAUTERY AS VFIB….AND IT MAY SHOCK.

Question 13

WHAT ARE THE TYPES OF CAUTERY? (USES) ?

Answer 13

TYPE: UNIPOLAR…MORE SPACE BTW CURRENT SOURCE AND GROUNDING PAD=MORE NOISE.
BIPOLAR…..CURRENT SOURCE AND GROUND ARE CLOSE. NOT A LOT OF POWER. LESS LIKELY TO DAMAGE CARDIAC DEVICES.
USE: COAGULATION…SHORT BURST. CUTTING…SUSTAINED CURRENT AND MORE LIKELY TO PRODUCE ELECTRIC MAGNETIC INTERFERENCE.

Question 14

WHAT 3 THINGS DOES DAMAGE TO A CRMD DEPEND ON?

Answer 14

1. STRENGTH OF SOURCE
2. DISTANCE OF THE LEADS
3. FREQUENCY OF THE SIGNAL

Question 15

HOW DO YOU USE CAUTERY SAFELY?

Answer 15

BIPOLAR BUT IF UNIPOLAR…..
NEVER HAVE DEVICE BTW GROUNDING PAD AND CAUTERY WAND, CAUTERY ONLY ON TISSUE (NOT AIR), SHORT BURSTS (8 SEC OR LESS) WITH LOW ENERGY. CONT. EKG PALP PULSE/ALINE.
PLACE GROUND PAD AS FAR FROM DEVICE AS POSSIBLE.

Question 16

WHAT SHOULD YOU PREPARE IN OR FOR PT WITH PACER/ICD?

Answer 16

12 LEAD, ATROPINE, RESUS CART, EXTERNAL PACE/DEFIB AVAILABLE AND ON PT, ALT METHOD TO IDENTIFY PULSE OTHER THAN EKG.

Question 17

WHAT INFO DO YOU NEED ABOUT PACER/ICD BEFORE YOU GO BACK?

Answer 17

MAKE, MODEL, LAST CHECKED, WHY DO YOU HAVE IT, UNDERLYING RHYTHM, EXPECTED MAGNENT RESPONSE, DOES HOSPITAL HAVE PROGRAMMER FOR THIS MODEL?

Question 18

WHAT SHOULD HAPPEN WHEN A MAGNET IS PLACED OVER PACER?

Answer 18

SENSING INACTIVATED SO IT GOES INTO ASYNCHRONOUS PACING ( USUALLY VOO/DOO…BUT NOT ALWAYS) MUST BE TAKEN OUT OF VOO/DOO MODE POST OP!!!!

Question 19

WHAT SHOULD HAPPEN WHEN MAGNET IS PLACED OVER ICD?

Answer 19

SHOULD HEAR A BEEP. CANT DETECT ARRYTHMIAS…CANT SHOCK. IT CAN STILL PROVIDE BRADY PACING. AFTER MAG REMOVED IT SHOULD SHOCK AGAIN BUT HAVE IT INTERROGATED POST OP.

Question 20

DO YOU ALWAYS PUT MAGNENT ON DEVICE?

Answer 20

NO! ONLY ON CERTAIN CASES BY TRAINED PERSONNEL. YOU CAN PUT ON MAG AS LAST RESORT IN EMERGENCIES BUT KNOW WHAT RESPONSE WILL BE! AFTER MAGNENT REMOVED PACER SHOULD GO BACK TO NORMAL BUT MUST BE INTERROGATED POST OP.

Question 21

HOW DO CERTAIN MEDICAL PROCEDURES AFFECT PACERS/ICD?

Answer 21

MRI:  INHIBITS IT.  CONTRAINDICATED WITH THESE PTS.
ESWL:  AVOID IF DEVICE IN ABDOMEN.
ECT: ICD SHOULD BE DISABLED.
ENDO WITH CAUTERY:  ICD DISABLED.
TENS:  OK
PA CATH INSERTION:  DISABLE ICD.

Question 22

HOW DOES K AFFECT PACING?

Answer 22

K AFFECTS THRESHOLD.
LOW K: LOSS OF PACEMAKER CAPTURE:
HIGH K: CAN LEAD TO VT

Question 23

WHAT ARE ANES. CONSIDERATIONS FOR INSERTION OF PERMANENT DEVICE? OR EPICARDIAL PACER?

Answer 23

LOCAL WITH SEDATION. EPICARDIAL PACER: GA
5 LEAD. CONTINUOUS PERIPH PULSE MONITORING, PACE/DEFIB PADS AVAILABLE . ATROPINE, ISOPROTERENOL AVAILABLE.
NO N2O. AVOID FASCICULATIONS AND SHIVERING.
AVOID ANTIARRHYTMIC DRUGS(LIDO)
GIVE BOLUS OF PROPOFOL WEHN TESTING ICD. DONT LET THEM MOVE ARM ON OPERATIVE SIDE. INTERROGATE DEVICE. CHEST XRAY.

Question 24

WHY IS TEE DONE PRIOR TO CARDIOVERSION?

Answer 24

TO LOOK FOR CLOTS. ENSURE THEYVE BEEN NPO.

Question 25

WHAT ARE THE DISADVANTAGES TO AN AP STUDY?

Answer 25

LONG NON STIM SEDATION CASES WITHOUT ACCESS TO AIRWAY…OFFSITE.

Question 26

DO PATIENTS NEED A PACEMAKER AFTER AN AV NODE ABLATION…….?

Answer 26

YES! AND 25% AFTER AN AVN MODIFICATION