PACEMAKER INTERPRETATION AND DEVICE MANAGEMENT PART I

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Beverley Thomas
6 years ago
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IN THEIR PRACTICE, FEEL EMPOWERED TO ACCESS FURTHER LEARNING, AND INTEGRATE EVIDENCE BASED COMPETENCIES INTO THEIR

1 1 PACEMAKER INTERPRETATION AND DEVICE MANAGEMENT PART I Cynthia Webner DNP, RN, CCNS, CCRN-CMC Karen Marzlin DNP, RN, CCNS, CCRN-CMC 2 PROFESSIONAL NURSING PRACTICE CAN ONLY ADVANCE AS MUCH AS INDIVIDUAL NURSES ARE AWARE THAT A KNOWLEDGE GAP EXISTS IN THEIR PRACTICE, FEEL EMPOWERED TO ACCESS FURTHER LEARNING, AND INTEGRATE EVIDENCE BASED COMPETENCIES INTO THEIR PROFESSIONAL PRACTICE TO PROVIDE SAFE, EFFECTIVE, EFFICIENT, PATIENT CENTERED, EQUITABLE CARE. Key Choice / CNEA 1

2 3 PACING BASICS Indications for Pacing Symptomatic bradycardia Sinus node dysfunction AV conduction system dysfunction - #1 Drug induced bradycardia 4 Key Choice / CNEA 2

3 Indications for Pacing 5 Symptomatic bradycardia Symptomatic heart blocks Chronic bifasicular and trifasicular blocks Sick Sinus Syndrome Neurocardiogenic Syncope Hypertrophic Cardiomyopathy Cardiac support for treatment of arrhythmias requiring ablation and / or medications resulting in bradycardia Pacing for termination of tachyarrhythmias (part of ICD therapy) CHF (biventricular pacing) Types of Cardiac Pacing 6 Temporary Transvenous Pacing Transcutaneous Pacing Epicardial Pacing Permanent Pacing Single chamber Dual chamber Biventricular Rate adaptive pacing Key Choice / CNEA 3

4 Temporary Pacemakers 7 Transcutaneous Pacer 8 Key Choice / CNEA 4

5 Epicardial Pacer 9 10 Permanent Pacemakers Key Choice / CNEA 5

6 11 Battery / Brains Pacer Parts Leads Implantation of Permanent Pacer 12 Key Choice / CNEA 6

7 13 Left Bundle Branch Block Key Choice / CNEA 7

Button Positive / Negative wire connections Heart Rate Dial MA

8 Left Bundle Branch Block V 6 = wide R V 1 = QS QRS =.12 sec or more 15 V1 = rs Component of TTVP Generator On / Off Button Positive / Negative wire connections Heart Rate Dial MA Milliamps Mode Demand / Asynchronous Battery 16 Sensitivity Key Choice / CNEA 8

9 TTVP Documentation 17 MA 2 Rate 70 Full Demand Dressing dry and intact to insertion site (with or without sutures) Pulse and circulation check distal to the insertion site All connections secured and tight Rhythm: Ex. 1:1 AV pacing with Capture Post TTVP Considerations 18 Wires secured to pacer pack Wires secured to patient All connections tight Occlusive dressing changed every 24 hours Special care with confused patients Key Choice / CNEA 9

10 Permanent Pacemaker Insertion 19 Electrophysiology Lab or Cardiac Catheterization Lab or Operating Room Local anesthesia Strict adherence to infection control procedures Pacer can Battery and brains Leads Pacemaker Function 20 Key Choice / CNEA 10

11 Bipolar vs. Unipolar Pace Ability of the pacemaker to send a stimulus to the myocardium Identified by a pacemaker spike on the ECG Capture Ability of the pacing stimulus to depolarize chamber being paced Identified by a pacemaker spike that is immediately followed by a P wave or a QRS complex on the ECG Sense Ability of the pacemaker to recognize and respond to intrinsic cardiac depolarization Identified by pacing when no intrinsic beats and not pacing when intrinsic beats are present Key Choice / CNEA 11

$Capture 24 Pacing stimulus results in depolarization of chamber being paced Each spike should be followed by a QRS unless it falls in heart s refractory period Key Choice /$

12 Pacing 23 Identify automatic pacing interval (pacing rate) Two consecutive pacer spikes Spikes should appear regularly unless pacer is inhibited by sensed intrinsic activity Capture 24 Pacing stimulus results in depolarization of chamber being paced Each spike should be followed by a QRS unless it falls in heart s refractory period Key Choice / CNEA 12

Sensing 25 Pacemaker sees and responds to intrinsic activity Must be given opportunity to sense Must be in demand mode There must be intrinsic activity to be sensed Revised NASPE/BPEG Generic Code

13 Sensing 25 Pacemaker sees and responds to intrinsic activity Must be given opportunity to sense Must be in demand mode There must be intrinsic activity to be sensed Revised NASPE/BPEG Generic Code for Antitachycardia Pacing 26 Position I Position II Position III Position IV Position V Chamber(s) Paced Chamber(s) Sensed Response to Sensing Rate Modulation Multisite O=None O=None O=None O=None O=None A=Atrium A=Atrium T=Triggered R=Rate modulation P=Paced V=Ventricle V=Ventricle I=Inhibited S=Shocks D=Dual (A+V) D=Dual (A+V) D=Dual (T+I) D=Dual (P+SV) (Bernstein et al., 2002) Key Choice / CNEA 13

14 27 UNDERSTANDING PACEMAKER FUNCTION 28 Key Choice / CNEA 14

15 29 AAI Pacing Atrial Inhibited AAI Paces the Atrium AAI Senses the Atrium AAI Atrial sensing inhibits atrial pacing 30 Pacing Modes AAI Key Choice / CNEA 15

16 VVI Pacing Ventricular Inhibited 31 VVI Paces the Ventricle VVI Senses the Ventricle VVI Ventricular sensing inhibits ventricular pacing 32 VVI Pacing Key Choice / CNEA 16

17 Dual Chamber Pacers 33 Provide AV synchrony Maintains atrial kick Improves hemodynamics in those with heart blocks Tracks atrial activity Ventricular pacing occurs in response to atrial activity Improved hemodynamics Decreased incidence of pacemaker syndrome Basic Pacemaker Timing 34 AV Interval Period of time between an atrial event (sensed P wave or atrial pace) and a paced ventricular event VV Interval Period of time from ventricular complex to ventricular complex VA Interval Ventricular complex to atrial activity Also called AEI or atrial escape interval Key Choice / CNEA 17

$35 Basic Pacemaker Timing Refractory Period Brief period of time when pacer is not allowed to look for intrinsic events Absolute Refractory Period Nothing can be sensed Relative Refractory Period$

18 35 Basic Pacemaker Timing Refractory Period Brief period of time when pacer is not allowed to look for intrinsic events Absolute Refractory Period Nothing can be sensed Relative Refractory Period Allows sensing but pacer will not respond Basic Pacemaker Timing 36 Low Rate Lowest rate allowed by the pacer before a paced beat is initiated High Rate Upper rate limit Highest rate that can be achieved and still maintain AV synchrony Key Choice / CNEA 18

19 DDDR Pacing 37 DDDR Paces both Atrium and Ventricle DDDR Senses both Atrium and Ventricle DDDR 1. Atrial sensing inhibits atrial pacing and triggers ventricular pacing 2. Ventricular sensing inhibits ventricular and atrial pacing 38 Key Choice / CNEA 19

20 39 DDD Pacing: AV Sequential Pacing State 40 DDD Pacing: Atrial Pacing State Key Choice / CNEA 20

21 41 DDD Pacing: Atrial Tracking State DDD Pacing: Atrial Sensing and Ventricular Sensing State 42 Key Choice / CNEA 21

22 43 TROUBLESHOOTING PACEMAKERS 44 Questions To Ask Key Choice / CNEA 22

45 Troubleshooters Toolbox Rhythm strip V1 or

23 45 Troubleshooters Toolbox Rhythm strip V1 or the lead that best allows evaluation of the pacemaker Pacemaker information Type Programmed parameters Intervals Special features Calipers Magnet Chest x-ray Questions to Ask 46 Are there pacemaker spikes? Key Choice / CNEA 23

24 47 Questions to Ask Is there evidence of pacemaker capture after a pacemaker spike? Atrial Capture Ventricular Capture 48 Questions to Ask Does the pacemaker sense appropriately Inhibit the pacemaker when a natural beat occurs? Activate pacing when no intrinsic beat occurs Sensed appropriately Key Choice / CNEA 24

Primary Potential Problems 49 Failure to Pace / Fire / Release Impulse Failure to Capture (depolarization) Failure to Sense Oversensing Undersensing 50 Troubleshooting Pacemakers Failure to Pace

25 Primary Potential Problems 49 Failure to Pace / Fire / Release Impulse Failure to Capture (depolarization) Failure to Sense Oversensing Undersensing 50 Troubleshooting Pacemakers Failure to Pace Pacer does not fire when indicated Pacer spike is not present when expected Recognized by pauses longer than the automatic interval or the absence of pacer spike at the end of the escape interval Key Choice / CNEA 25

26 Troubleshooting Pacemakers 51 Causes of Failure to Fire Pacer turned off Loose or broken connection Lead displacement Battery depletion Oversensing Troubleshooting Pacemakers 52 Interventions for Failure to Fire Emergently treat patient as condition requires Check connections if temporary Replace battery or pulse generator Lead repositioning or replacement Convert pacer to asynchronous mode to assess for sensitivity issues Key Choice / CNEA 26

$Pacemakers 54 Causes of Failure to Capture Lead displacement Increased pacing thresholds AMI Chamber perforation Impulse occurs during intrinsic refractory period Key Choice$

27 Troubleshooting Pacemakers 53 Failure to Capture Pacemaker fires but depolarization does not occur Recognized by spike not followed by depolarization Troubleshooting Pacemakers 54 Causes of Failure to Capture Lead displacement Increased pacing thresholds AMI Chamber perforation Impulse occurs during intrinsic refractory period Key Choice / CNEA 27

Troubleshooting Pacemakers 55 Interventions for Failure to Capture Emergently treat patient as condition requires Position patient on left side May need lead repositioned or replaced Increase MA

28 Troubleshooting Pacemakers 55 Interventions for Failure to Capture Emergently treat patient as condition requires Position patient on left side May need lead repositioned or replaced Increase MA Replace battery or pulse generator Chest x-ray, Labs Monitor for tamponade, diaphragmatic pacing Troubleshooting Pacemakers 56 Failure to Sense (Undersensing) Pacer fails to recognize intrinsic activity Recognized by pacer spikes falling closer to the intrinsic beats than the escape interval; spikes land indiscriminately throughout the cardiac cycle Key Choice / CNEA 28

$Undersensing Asynchronous mode Intrinsic ventricular activity in refractory period Lead placement or AMI Low QRS voltage Break in connection Faulty generator Battery failure Key Choice /$

29 Sensitivity: The Fence 57 Sensitivity too low (fence too high) Pacer can t see QRS Sensitivity too high (fence too low) Pacer hallucinates Troubleshooting Pacemakers 58 Causes of Undersensing Asynchronous mode Intrinsic ventricular activity in refractory period Lead placement or AMI Low QRS voltage Break in connection Faulty generator Battery failure Key Choice / CNEA 29

$not on asynchronous Increase sensitivity Check connections Treat PVC s Change pacer rate dependent of patients own rhythm Chest X-ray to verify position and check for lead fractures Change from$

30 Troubleshooting Pacemakers 59 Interventions for Undersensing Emergently treat patient as condition requires Position on left side Lead positioning or replacement may be necessary Make sure pacer is not on asynchronous Increase sensitivity Check connections Treat PVC s Change pacer rate dependent of patients own rhythm Chest X-ray to verify position and check for lead fractures Change from bipolar system to unipolar system to increase sensing signal 60 Troubleshooting Pacemakers Failure to Sense (Oversensing) Pacemaker recognizes extraneous electrical activity or the wrong intrinsic electrical activity as the inhibiting event Recognized by the absence of pacer spikes and failure to fire Key Choice / CNEA 30

31 Troubleshooting Pacemakers 61 Causes of Oversensing Sensitivity set too high Electromagnetic interference Myopotentials T wave potentials Troubleshooting Pacemakers 62 Interventions for Oversensing Decrease sensitivity If MA is high decrease Chest X-ray to assess lead placement Remove from EMI Ensure that all equipment is properly grounded Switch from unipolar to bipolar Key Choice / CNEA 31

32 63 TRUE OR FALSE: WHEN YOU PLACE THE MAGNET OVER A PERMANENT PACEMAKER THE PACEMAKER SHOULD PACE. Magnet Mode 64 Beware of the Magnet! FUNCTIONS DIFFERENTLY WITH ICD S Turns sensing circuit off Pacemaker paces asynchronously Identifies battery end of life Determines lead location RV Pacing LV Pacing Risk of pacemaker impulse occurring on the T wave Should not be used without caution Avoid use in those patients susceptible to ventricular arrhythmias: Fresh MI Hypokalemia Key Choice / CNEA 32

33 65 66 LET S PRACTICE Key Choice / CNEA 33

34 Let s Practice DDDR Pacer 67 Let s Practice DDDR Pacer 68 Key Choice / CNEA 34

35 Let s Practice VVI 69 Let s Practice VVI Pacer 70 Key Choice / CNEA 35

36 71 Fire? Capture? Sense? Let s Practice DDDR 72 Key Choice / CNEA 36

37 Let s Practice DDDR 73 Let s Practice VVI Pacer 74 Key Choice / CNEA 37

38 Let s Practice DDDR Pacer BE THE BEST THAT YOU CAN BE EVERY DAY. YOUR PATIENTS ARE COUNTING ON IT! Key Choice / CNEA 38

39 Thank You! 77 Key Choice / CNEA 39

Puzzling Pacemakers Cheryl Herrmann, APN, CCRN, CCNS-CSC-CMC

Puzzling Pacemakers Cheryl Herrmann, APN, CCRN, CCNS-CSC-CMC Pacemaker: An electric device implanted in the body to regulate the heart beat. Delivers electrical stimuli over leads with electrodes in contact