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Cardiac Issues 2011

Kevin P Foley MD FACC Yakima Heart Center Yakima Washington. Cardiac Issues 2011. Temporary Pacing. Bradycardia: MI, hyperK, Ischemic/Coronary Disease, drug effects, post cardiac surgery Methods available: transvenous, epicardial, transthoracic Available technology

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Cardiac Issues 2011

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  1. Kevin P Foley MD FACC Yakima Heart Center Yakima Washington Cardiac Issues 2011

  2. Temporary Pacing • Bradycardia: MI, hyperK, Ischemic/Coronary Disease, drug effects, post cardiac surgery • Methods available: transvenous, epicardial, transthoracic • Available technology • Issues in care and monitoring

  3. Transvenous Pacing • Venous access: subclavian, internal jugular, femoral, antecubital • Pacing catheters • Straight or J tipped • Solid or balloon guided • Fluoroscopy: Portable C arm or Cath Lab • Resuscitation equipment available

  4. Temporary Pacing Bipolar Contacts: negative to tip Proximal to Positive (P-P)

  5. Temporary Pacing Balloon guided multipurpose Catheter with electrical connec

  6. Temporary Pacing Older style Connecting wire With unshrouded Pins Newer wires are shrouded

  7. Pacemaker Connections • Shrouded connector • !Compatible connections!

  8. Temporary Pacing Temporary Pacer: select rate, output (MA), sensitivity

  9. Temporary Pacing X-ray appearance: Atrial J shaped Ventricular: apex RV

  10. Temporary Pacing--Procedure • Sterile technique • Vascular access • Place temporary pacing catheter • Connect to pacer box • Assess capture: high output, reduce, note when capture lost • Assess sensing: see next slide • SECURE the pacing catheter • Post insertion chest X-ray for position and possible pneumothorax

  11. Assessing Sensing • If temporary box capable: directly measure size of R and P waves • If not: set sensitivity to maximum • Set demand rate low enough to allow the patient to have their own rhythm • Back off demand dial until appropriate sensing lost—That position is “Sensing Threshold”

  12. Loss of capture • Assess rhythm: sense—capture--timing • Immediately check connections: tight, intact • Increase output of pacer • Reposition patient • Invert polarity • Consider conversion from bipolar to unipolar path

  13. Bipolar to Unipolar Conversion • Pacing lead tip connection (negative, black) remains connected • Proximal connection (positive, red) jumped with alligator wire to monitor contact on patient’s chest • Maximum output from pacer • Rarely done

  14. Epicardial Pacemaker • Most commonly post op cardiac surgery • Same principles of pacing • Same generator • May be atrial and ventricular connections • Caution with connectors: electrically isolate • May be patient positional issues

  15. Transthoracic Pacing

  16. Transthoracic Pacing • Note: MONITOR: DEFIB • Rate and MA Controls

  17. Transthoracic Pacing • Emergent alternative • External patches to patients chest (A-P > ant chest • Know your external pacer/defibrillator controls • Increase power output (mA) to point of capture • May cause patient discomfort

  18. Problems of Transthoracic Pacing • Stimulus overloads regular ECG monitors: patient ECG ‘blown away’ • Hard to assess capture on small screen monitor • Delivery of transthoracic stim causes muscle contraction and transmitted pressure wave to groin—Hard to be certain of femoral pulse in a critical situation

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