Temporary Pacemaker Slides

1. PacemakersPacemakers

2. PacemakersPacemakers
Pacemakers are the electronic Pacemakers are the electronic
devices that can be used to initiate devices that can be used to initiate
the heartbeat when the heart’s the heartbeat when the heart’s
intrinsic electrical system cannot intrinsic electrical system cannot
effectively generate a rate adequate effectively generate a rate adequate
to support cardiac outputto support cardiac output

3. Types of PacemakerTypes of Pacemaker
Temporary pacemakerTemporary pacemaker
Permanent pacemakerPermanent pacemaker

4. Temporary PacemakerTemporary Pacemaker
Temporary Pacemakers can be used Temporary Pacemakers can be used
temporarily , either supportively or temporarily , either supportively or
prophylactically, until the condition prophylactically, until the condition
responsible for the rate or responsible for the rate or
conduction disturbance resolves .conduction disturbance resolves .

5. IndicationsIndications
BradycardiaBradycardia
•Sinus bradycardia and arrestSinus bradycardia and arrest
•Sick sinus syndromeSick sinus syndrome
•Heart blocksHeart blocks
TachydysrhythmiasTachydysrhythmias
•SupraventricularSupraventricular
•VentricularVentricular
Permanent pacemaker failurePermanent pacemaker failure
Support cardiac output after cardiac surgerySupport cardiac output after cardiac surgery
Diagnostic studiesDiagnostic studies
•Electrophysiological studiesElectrophysiological studies
•Atrial electrogramAtrial electrogram

6. The Pacemaker SystemThe Pacemaker System
A simple electrical circuit consisting of A simple electrical circuit consisting of
PULSE GENERATORPULSE GENERATOR
PACING LEAD PACING LEAD

7. Pulse GeneratorPulse Generator

8. Pacing pulse generatorPacing pulse generator
The pulse generator is designed to The pulse generator is designed to
generate an electrical current that travels generate an electrical current that travels
through pacing lead and exits through through pacing lead and exits through
electrode that is in direct contact with the electrode that is in direct contact with the
heart. This electrical current initiates a heart. This electrical current initiates a
myocardial depolarization.myocardial depolarization.
The power source for a temporary external The power source for a temporary external
pulse generator is standard 9-volt alkaline pulse generator is standard 9-volt alkaline
battery inserted into the generatorbattery inserted into the generator

9. Pacing Lead SystemPacing Lead System
The pacing lead used for temporary The pacing lead used for temporary
pacing may be bipolar or unipolar pacing may be bipolar or unipolar

Bipolar Pacing SystemBipolar Pacing System
In bipolar pacing system, two In bipolar pacing system, two
electrodes (positive and negative) are electrodes (positive and negative) are
located within the heartlocated within the heart

10. Bipolar Pacing SystemBipolar Pacing System
The bipolar lead used in the The bipolar lead used in the
transvenous pacing as two electrodestransvenous pacing as two electrodes
on one catheter.on one catheter.
The distal , or negative , electrode is The distal , or negative , electrode is
at the tip of the pacing lead and is in at the tip of the pacing lead and is in
the direct contact with the heart, the direct contact with the heart,
usually inside the right atrium or usually inside the right atrium or
ventricle. ventricle.

11. Bipolar pacing systemBipolar pacing system
Approximately 1 cm from the Approximately 1 cm from the
negative electrode is a positive negative electrode is a positive
electrode .electrode .
The negative electrode is attached to The negative electrode is attached to
the negative terminal, and the the negative terminal, and the
positive electrode is attached to the positive electrode is attached to the
positive terminal of the pulse positive terminal of the pulse
generator, either directly or via a generator, either directly or via a
bridging cablebridging cable

12. Bipolar pacing systemBipolar pacing system
An epicardial lead system is often used for An epicardial lead system is often used for
temporary pacing after cardiac surgerytemporary pacing after cardiac surgery
The bipolar epicardial lead system has two The bipolar epicardial lead system has two
separate insulated wires (one negative and separate insulated wires (one negative and
one positive) that are loosely secured with one positive) that are loosely secured with
sutures to the cardiac chambers to be sutures to the cardiac chambers to be
paced. Both electrodes are in contact with paced. Both electrodes are in contact with
myocardial tissues, so either wire may be myocardial tissues, so either wire may be
use as the negative, or ground electrodeuse as the negative, or ground electrode

13. Bipolar LeadBipolar Lead

14. Unipolar Pacing SystemUnipolar Pacing System
A unipolar pacing system has only A unipolar pacing system has only
one electrode (the negative one electrode (the negative
electrode) making contact with the electrode) making contact with the
heart.heart.
In the case of unipolar epicardial lead In the case of unipolar epicardial lead
system, the positive can be formed system, the positive can be formed
by a piece of surgical steel wire sewn by a piece of surgical steel wire sewn
into the sucutaneous tissue of the into the sucutaneous tissue of the
chest chest

15. Unipolar LeadUnipolar Lead

16. Pacing RoutesPacing Routes
Transcutaneous pacingTranscutaneous pacing
Transthoracic pacingTransthoracic pacing
Epicardial pacingEpicardial pacing
Transvenous pacingTransvenous pacing

17. Transvenous pacingTransvenous pacing
It involves threading an electrode It involves threading an electrode
catheter through a vein into the right catheter through a vein into the right
atrium or right ventricle. Five different atrium or right ventricle. Five different
veins can be used.veins can be used.
Antecubital approachAntecubital approach
Femoral approachFemoral approach
SubclavianSubclavian
Internal jugularInternal jugular
External jugularExternal jugular

18. Pacemaker terminologyPacemaker terminology
Fixed rate (Asynchronous)Fixed rate (Asynchronous)
Delivers a pacing stimulus at a set Delivers a pacing stimulus at a set
(fixed) rate regardless of the (fixed) rate regardless of the
occurrence of spontaneous occurrence of spontaneous
myocardial depolarization; occurs in myocardial depolarization; occurs in
non-sensing modes. It delivers an non-sensing modes. It delivers an
electrical impulse at a present fixed electrical impulse at a present fixed
rate to the heart and functions rate to the heart and functions
independently of cardiac activity. independently of cardiac activity.

19. Pacemaker TerminologyPacemaker Terminology
Demand (synchronous)Demand (synchronous)
Delivers a pacing stimulus only when the Delivers a pacing stimulus only when the
heart’s intrinsic pacemaker fails to function heart’s intrinsic pacemaker fails to function
at a predetermined rate; the pacing at a predetermined rate; the pacing
stimulus is either inhibited or triggered by stimulus is either inhibited or triggered by
the sensing of intrinsic activity. the sensing of intrinsic activity.
The pulse generator delivers artificial The pulse generator delivers artificial
stimulus only when needed or on demand stimulus only when needed or on demand
and therefore does not compete with and therefore does not compete with
patient’s rhythmpatient’s rhythm

20. Pacemaker TerminologyPacemaker Terminology
Atrioventricular (AV) Sequential (DualAtrioventricular (AV) Sequential (Dual
Chamber)Chamber)
Delivers a pacing stimulus to both the Delivers a pacing stimulus to both the
atrium and ventricle in physiologic atrium and ventricle in physiologic
sequence with sufficient AV delay to sequence with sufficient AV delay to
permit adequate ventricular fillingpermit adequate ventricular filling

21. Examples of Temporary Pacing Examples of Temporary Pacing
ModesModes
Asynchronous UniversalAsynchronous Universal
AOO DDD AOO DDD

VOOVOO
DOODOO
Synchronous Synchronous
AAIAAI
VVIVVI
DVIDVI

22. Pacemaker SettingsPacemaker Settings
RATERATE
OUTPUTOUTPUT
SENSITIVITYSENSITIVITY

23. RATERATE
It regulates the number of impulse that can It regulates the number of impulse that can
be delivered to the heart per minute.be delivered to the heart per minute.
The rate setting depend on the The rate setting depend on the
physiological needs of the patient, but it is physiological needs of the patient, but it is
generally maintained between 60-80 beats/generally maintained between 60-80 beats/
min.min.
If the pacemaker is operating in dual-If the pacemaker is operating in dual-
chamber mode, the ventricular control rate chamber mode, the ventricular control rate
also regulate the atrial rate. also regulate the atrial rate.

24. OUTPUTOUTPUT
It is the amount of electrical current It is the amount of electrical current
(measured in milliamperes [mA]) that (measured in milliamperes [mA]) that
is delivered to the heart to initiate is delivered to the heart to initiate
depolarization.depolarization.
The point at which depolarization The point at which depolarization
occurs is termed threshold and is occurs is termed threshold and is
indicated by a myocardial response to indicated by a myocardial response to
the pacing stimulus (capture) the pacing stimulus (capture)

25. SENSITIVITYSENSITIVITY
The sensitivity control regulates the The sensitivity control regulates the
ability of the pacemaker to the heart’sability of the pacemaker to the heart’s
intrinsic electrical activity.intrinsic electrical activity.
Sensitivity is measured in millivolts Sensitivity is measured in millivolts
(mV) and determines the size of the (mV) and determines the size of the
intracardiac signal that generator will intracardiac signal that generator will
recognize recognize

26. PACINING ARTIFACTSPACINING ARTIFACTS
All patients with temporary All patients with temporary
pacemaker require continuous ECG pacemaker require continuous ECG
monitoring.monitoring.
The pacing artifact is the spike that is The pacing artifact is the spike that is
seen on the ECG tracing as the pacing seen on the ECG tracing as the pacing
stimulus is delivered to the heart.stimulus is delivered to the heart.
A P wave is visible after the pacing A P wave is visible after the pacing
artifact if atrium is being paced.artifact if atrium is being paced.

27. Pacing ArtifactsPacing Artifacts

28. Pacing artifactsPacing artifacts

29. Pacing ArtifactPacing Artifact

30. ADVERSE EFFECTSADVERSE EFFECTS
Muscle stimulationMuscle stimulation
PneumothoraxPneumothorax
Ectopic beats like PVC’sEctopic beats like PVC’s
Ventricular perforationVentricular perforation
Perforation of other organs like Perforation of other organs like
LiverLiver
StomachStomach
DiaphragmDiaphragm

31. --
TroubleshootingTroubleshooting
IN TPIIN TPI

32. Failure to Fire Failure to Fire
 Failure of the pacemaker deliver the Failure of the pacemaker deliver the
pacing stimulus results in the pacing stimulus results in the
disappearance of the pacing artifact, disappearance of the pacing artifact,
even though the patient’s intrinsic even though the patient’s intrinsic
rate is less than the set rate on the rate is less than the set rate on the
pacer. This can occur either pacer. This can occur either
intermittently or continuously and can intermittently or continuously and can
be attributed to failure of the pulse be attributed to failure of the pulse
generator or its battery generator or its battery

33. Failure to fireFailure to fire

34. Failure to fireFailure to fire
CAUSESCAUSES
Loose head hookupsLoose head hookups
Dead batteryDead battery
Malfunctioning pulse generatorMalfunctioning pulse generator

35. Failure to fireFailure to fire
INTERVENTIONSINTERVENTIONS
Secure lead hookupsSecure lead hookups
Replace batteryReplace battery
Replace pulse generatorReplace pulse generator

36. Failure to CaptureFailure to Capture
If the pacing stimulus fires but fails to If the pacing stimulus fires but fails to
initiate a myocardial depolarization, a initiate a myocardial depolarization, a
pacing artifact will be present but will pacing artifact will be present but will
not be followed by the expected P not be followed by the expected P
wave or QRS complex, depending on wave or QRS complex, depending on
the chamber being paced. the chamber being paced.

37. Failure to CaptureFailure to Capture

38. Failure to CaptureFailure to Capture
CAUSESCAUSES
Pacemaker output too lowPacemaker output too low
Catheter dislodgedCatheter dislodged
Loose connectionsLoose connections

39. Failure to CaptureFailure to Capture
INTEREVENTIONSINTEREVENTIONS
Increase pacemaker outputIncrease pacemaker output
Reposition catheterReposition catheter
Secure all connectionsSecure all connections

40. Failure to SenseFailure to Sense
UNDERSENSINGUNDERSENSING
In it pacemaker fires at wrong times In it pacemaker fires at wrong times
or for the wrong reasons (help being or for the wrong reasons (help being
given when none is needed)given when none is needed)
OVERSENSINGOVERSENSING
In it pacemaker fires incorrectly In it pacemaker fires incorrectly
senses depolarization and refuses to senses depolarization and refuses to
fire when it should (won’t pace when fire when it should (won’t pace when
the patient actually needs it)the patient actually needs it)

41. Failure to SenseFailure to Sense

42. Failure to senseFailure to sense
CAUSESCAUSES
Electrolyte imbalanceElectrolyte imbalance
Disconnection or dislodgement ofDisconnection or dislodgement of
leadlead
Edema or fibrosis at the tip of Edema or fibrosis at the tip of
electrodeelectrode
Drug interactionDrug interaction
Drug batteryDrug battery

43. Failure to senseFailure to sense
INTERVENTIONINTERVENTION
Correct the sensitivity settingCorrect the sensitivity setting
Replace batteryReplace battery
Secure all connectionsSecure all connections
Correct the underlying causeCorrect the underlying cause

44. Medical ManagementMedical Management
The physician determines the pacing The physician determines the pacing
route based on the patient’s clinical route based on the patient’s clinical
situation. Generally transcutaneous situation. Generally transcutaneous
pacing is used in emergent situations pacing is used in emergent situations
until a transvenous lead can be until a transvenous lead can be
secured. secured.

45. Medical ManagementMedical Management
If the patient is undergoing heart If the patient is undergoing heart
surgery, epicardial leads may be surgery, epicardial leads may be
electively placed at the end of the electively placed at the end of the
operation. The physician places the operation. The physician places the
transvenous or epicardial pacing transvenous or epicardial pacing
lead(s), repositioning as needed to lead(s), repositioning as needed to
obtain adequate pacing and sensing obtain adequate pacing and sensing
thresholds. thresholds.

46. Nursing ManagementNursing Management
 Four primary areas:Four primary areas:
Assessment and prevention of Assessment and prevention of
pacemaker malfunction, pacemaker malfunction,
Protection against micro shock, Protection against micro shock,
Surveillance for complications Surveillance for complications
such as infection such as infection
Patient education. Patient education.

47. Prevention of Pacemaker Prevention of Pacemaker
MalfunctionMalfunction
 Continuous ECG monitoring is essential to Continuous ECG monitoring is essential to
facilitate prompt recognition and facilitate prompt recognition and
appropriate intervention for pacemaker appropriate intervention for pacemaker
malfunction. malfunction.
The temporary pacing lead and bridging The temporary pacing lead and bridging
cable must be properly secured to the body cable must be properly secured to the body
with tape to prevent the accidental with tape to prevent the accidental
displacement of the electrode, which can displacement of the electrode, which can
result in failure to pace or sense. result in failure to pace or sense.
The external pulse generator can be The external pulse generator can be
secured to the patient’s waist with a strap secured to the patient’s waist with a strap

48. Prevention of Pacemaker Prevention of Pacemaker
MalfunctionMalfunction
 For the patient on a regimen of bed rest, For the patient on a regimen of bed rest,
the pulse generator can be suspended with the pulse generator can be suspended with
twill tape from an intravenous (IV) pole twill tape from an intravenous (IV) pole
mounted overhead on the ceiling.mounted overhead on the ceiling.
This not only will prevent tension on the This not only will prevent tension on the
lead while the patient is moved (given lead while the patient is moved (given
adequate length of bridging cable) but will adequate length of bridging cable) but will
also alleviate the possibility of accidental also alleviate the possibility of accidental
dropping of the pulse generator.dropping of the pulse generator.

49. Prevention of Pacemaker Prevention of Pacemaker
MalfunctionMalfunction
The nurse inspects for:The nurse inspects for:
 loose connections between the lead(s) and loose connections between the lead(s) and
pulse generator on a regular basis. pulse generator on a regular basis.
Replacement batteries and pulse generator Replacement batteries and pulse generator
must always be available on the unit. must always be available on the unit.
 The battery has an anticipated lifespan of The battery has an anticipated lifespan of
1 month, it probably is sound practice to 1 month, it probably is sound practice to
change the battery if the pacemaker has change the battery if the pacemaker has
been operating continually for several days.been operating continually for several days.

50. Prevention of Pacemaker Prevention of Pacemaker
MalfunctionMalfunction
 Pulse generators (new generation) Pulse generators (new generation)
provide a low-battery signal 24 hours provide a low-battery signal 24 hours
before complete loss of battery before complete loss of battery
function to prevent inadvertent function to prevent inadvertent
interruptions in pacing. The pulse interruptions in pacing. The pulse
generator must always be labeled generator must always be labeled
with the date that the battery was with the date that the battery was
replaced. replaced.

51. Micro-shock ProtectionMicro-shock Protection
 It is important to be aware of all It is important to be aware of all
sources of EMI within the critical care sources of EMI within the critical care
environment that could interfere with environment that could interfere with
the pacemaker’s function. Sources of the pacemaker’s function. Sources of
EMI in the clinical area include EMI in the clinical area include
electrocautery, defibrillation current, electrocautery, defibrillation current,
radiation therapy, magnetic radiation therapy, magnetic
resonance imaging devices, and resonance imaging devices, and
transcutaneous electrical nerve transcutaneous electrical nerve
stimulation (TENS) units. stimulation (TENS) units.

52. Micro-shock ProtectionMicro-shock Protection
In most cases, if EMI is suspected of In most cases, if EMI is suspected of
precipitating pacemaker malfunction, precipitating pacemaker malfunction,
converting to asynchronous mode (fixed converting to asynchronous mode (fixed
rate) will maintain pacing until the cause of rate) will maintain pacing until the cause of
the EMI is removed.the EMI is removed.
The pacing electrode provides a direct, low The pacing electrode provides a direct, low
resistance path to the heart, the nurse resistance path to the heart, the nurse
takes special care while handling the takes special care while handling the
external components of the pacing system external components of the pacing system
to avoid conducting stray electrical current to avoid conducting stray electrical current
from other equipment.from other equipment.

53. InfectionInfection
• Infection at the lead site is a rare but Infection at the lead site is a rare but
serious complication associated with serious complication associated with
temporary pacemakers. temporary pacemakers.
•The (sites) is carefully inspected for The (sites) is carefully inspected for
purulent drainage, erythema, and purulent drainage, erythema, and
edema, and the patient is observed edema, and the patient is observed
for the signs of systemic infection. for the signs of systemic infection.

54. InfectionInfection
Site care is performed according to Site care is performed according to
institution’s protocol. Although most institution’s protocol. Although most
infections remain localized, infections remain localized,
endocarditis can occur in patients endocarditis can occur in patients
with endocardial pacing leads.with endocardial pacing leads.
 A less common complication A less common complication
associated with transvenous pacing is associated with transvenous pacing is
myocardial perforation, which can myocardial perforation, which can
result in rhythmic hiccoughs or result in rhythmic hiccoughs or
cardiac tamponade. cardiac tamponade.

55. Example of two common Example of two common
programming codes:programming codes:
DDD DDD

Pace: Atrium and Ventricle Pace: Atrium and Ventricle

Sense: Atrium and Ventricle Sense: Atrium and Ventricle
Response: Inhibited and TriggeredResponse: Inhibited and Triggered
This is fully automatic or universal pacemaker This is fully automatic or universal pacemaker
 VVI VVI
Pace: Ventricle Pace: Ventricle

Sense: Ventricle Sense: Ventricle
Response: InhibitedResponse: Inhibited
Ventricular pacing, ventricular sensing, inhibited Ventricular pacing, ventricular sensing, inhibited
response to sensed QRS complexesresponse to sensed QRS complexes

56. EXAMPLES OF TEMPORARY EXAMPLES OF TEMPORARY
PACING MODESPACING MODES

Pacing Modes DescriptionPacing Modes Description
AsynchronousAsynchronous
AOO Atrial pacing, no AOO Atrial pacing, no

sensingsensing
VOO Ventricular pacing,no VOO Ventricular pacing,no

sensingsensing
DOO Atrial and ventricularDOO Atrial and ventricular
pacing, no sensing pacing, no sensing

57. EXAMPLES OF TEMPORARY EXAMPLES OF TEMPORARY
PACING MODESPACING MODES

Pacing Modes DescriptionPacing Modes Description
SynchronousSynchronous
AAI Atrial pacing, atrial sensing, AAI Atrial pacing, atrial sensing,
inhibited response to sensed P waveinhibited response to sensed P wave
VVI Ventricular pacing, ventricular VVI Ventricular pacing, ventricular
sensing, inhibited response to sensed sensing, inhibited response to sensed

QRS complexesQRS complexes
DVI Atrial and ventricular pacing, DVI Atrial and ventricular pacing,
ventricular sensing; both atrial and ventricular sensing; both atrial and
ventricular pacing are inhibited if a ventricular pacing are inhibited if a
spontaneous ventricular spontaneous ventricular
depolarization is sensed. depolarization is sensed.

58. EXAMPLES OF TEMPORARY EXAMPLES OF TEMPORARY
PACING MODESPACING MODES

Pacing Modes DescriptionPacing Modes Description
UniversalUniversal
DDD Both chambers are paced DDD Both chambers are paced
and sensed; inhibited and sensed; inhibited
response of the pacing stimuli to response of the pacing stimuli to
sensed events in their respective sensed events in their respective

chamber;triggered chamber;triggered

response to send atrial activity response to send atrial activity
to allow for rate – responsive to allow for rate – responsive
ventricular pacing.ventricular pacing.