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1 Pacemaker Simulator ST2361 Learning Material Ver.1.1 An ISO 9001:2008 company

2 Save paper, save trees, save earth Dear User, We request you to use the Learning material in the CD form provided with this supply. Your this act will help to save paper. Please remember that each paper manual requires sheets of paper on an average. Your CD learning material has colourful diagrams, plenty of theory, detailed experiments with observation tables, frequently asked questions, etc... and more so sometimes videos as well. - Scientech Eco Foundation Scientech Technologies Pvt. Ltd. 2

3 Scientech Technologies Pvt. Ltd. 3

4 Pacemaker Simulator ST2361 Table of Contents 1. Safety Instructions 6 2. Introduction 7 3. Features 8 4. Technical Specifications 9 5. Controls and Indicators Pacemaker Working Type of Pacemaker Hysteresis Operating Instructions Pacemaker Waves Diagram Experiments Experiment 1 25 Study of Normal Sinus Rhythm (Lead II) Experiment 2 26 Study of Bradycardia (Slower Heart Rate < 60) Experiment 3 27 Study of Corrected Bradycardia wave (Pacemaker Action) Experiment 4 28 Study of Tachycardia (Faster Heart Rate > 100) Experiment 5 29 Study of Corrected Tachycardia Wave (Pacemaker Action) Experiment 6 30 Study of Atrial Flutter (Impulse Travels in Circular course in atria) Experiment 7 31 Study of Corrected Atrial Flutter (Pacemaker Action) Experiment 8 32 Study of Atrial Fibrillation (Impulses have chaotic, random pathways in atria) Experiment 9 33 Study of Corrected Atrial Fibrillation (Pacemaker action) Experiment Study of Junction rhythm (Impulses originated at AV node with retrograde and ante grade direction) Experiment Study of Corrected Junction rhythm (Pacemaker Action) Scientech Technologies Pvt. Ltd. 4

5 Experiment Study of Premature Ventricular Contraction (A Single Impulse Originate at Right Ventricle) Experiment Study of Corrected Premature Ventricular Contraction (Pacemaker Action) Experiment Study of Ventricular Tachycardia (Impulse Originated at Ventricular Pacemaker) Experiment Study of Corrected Ventricular Tachycardia (Pacemaker Action) Experiment Study of Ventricular Fibrillation (Chaotic Ventricular depolarization) Experiment Study of Corrected Ventricular Fibrillation (Pacemaker Action) Experiment Study of II Degree AV Block (Sudden drop of QRS Complex) Experiment Study of Corrected II Degree AV Block (Pacemaker Action) Experiment Study of III degree AV Block (Impulses originate at AV node and Proceed to ventricles Atrial and ventricular activities are not synchronous) Experiment Study of Corrected III degree AV Block (Pacemaker Action) 13. Frequently Asked Questions Glossary of Human Cardiovascular System Terms Warranty List of Accessories 59 Scientech Technologies Pvt. Ltd. 5

6 Safety Instructions Read the following safety instructions carefully before operating the instrument. To avoid any personal injury or damage to the instrument or any product connected to it. Do not operate the instrument if suspect any damage to it. The instrument should be serviced by qualified personnel only. For your safety: Use proper Mains cord Ground the Instrument : Use only the mains cord designed for this instrument. Ensure that the mains cord is suitable for your country. : This instrument is grounded through the protective earth conductor of the mains cord. To avoid electric shock the grounding conductor must be connected to the earth ground. Before making connections to the input terminals, ensure that the instrument is properly grounded. Observe Terminal Ratings : To avoid fire or shock hazards, observe all ratings and marks on the instrument. Use only the proper Fuse : Use the fuse type and rating specified for this instrument. Use in proper Atmosphere : Please refer to operating conditions given in the manual. 1. Do not operate in wet / damp conditions. 2. Do not operate in an explosive atmosphere. 3. Keep the product dust free, clean and dry. Scientech Technologies Pvt. Ltd. 6

7 Introduction The rhythmic beating of the heart is due to the triggering pulses that originate in an area of specialized tissue in the right atrium of the heart. This area is known as (SA- Node) Sino-Atrial Node. In abnormal situations, if this natural pacemaker ceases to function or becomes unreliable or if the triggering pulse does not reach the heart muscles because of blocking by the damage tissues, the natural and normal synchronization of the heart action gets disturbed. When monitored, this manifests itself through a decrease in the heart rate and changes in the electrocardiogram (ECG) waveforms. By giving external electrical stimulations impulses to the heart muscles, it is possible to regulate the heart rate. These impulses are given by an electronic instrument called as Pacemaker. Pacemaker basically consist of two parts, an electronic unit which generates stimulating impulses of controlled rate and amplitude known as pulse generator while other part is lead which carry the electrical pulses from pulse generator to the heart. Scientech Technologies Pvt. Ltd. 7

8 Features Provides amplified Normal Sinus Rhythm output with P, Q, R, S, T waves Provides information about 10 abnormal (Diseased) waves which indicates particular abnormality in heart Provides information about 10 corrected wave which indicates possible wave shapes after Pacemaker action Provides information about pacemaker modes (Single/Dual) of operation Provides information about single as well as dual chamber pacing/sensing of heart Every Systolic action of heart is indicated by LED (visible) and audible (Buzzer) sound controls Scientech Technologies Pvt. Ltd. 8

9 Technical Specifications Pulse amplitude Range : 1-5 Vpp Pulse width Range : 1-7 mm Heartbeat Indication : Both visible (LED) and Audible (Buzzer) controls Output wave amplitude range : 1-5 Volts Power Supply : 220/110V ±10%, 50Hz / 60Hz Dimensions (mm) : W 360 D 260 H 120 Weight : 1 Kg (approximately) RoHS Compliance Scientech Products are RoHS Complied. RoHS Directive concerns with the restrictive use of Hazardous substances (Pb, Cd, Cr, Hg, Br compounds) in electric and electronic equipments. Scientech products are Lead Free and Environment Friendly. It is mandatory that service engineers use lead free solder wire and use the soldering irons upto (25 W) that reach a temperature of 450 C at the tip as the melting temperature of the unleaded solder is higher than the leaded solder. Scientech Technologies Pvt. Ltd. 9

10 Mimic Diagram Figure 1 Scientech Technologies Pvt. Ltd. 10

11 Controls and Indicators Power On/Off: Rocker switch for supplying power to the instrument On-board buzzer: Audio indication for each heartbeat event executed by heart of human body On-board LED: Visible indication for each systole of human Heart Selection Switch: A rotary switch is provided to select particular diseased wave Scientech Technologies Pvt. Ltd. 11

12 Pacemaker Working The pacemaker essentially does two things, it senses the patient s own rhythm using a sensing circuit and it sends out electrical signals using an output circuit. If the patient s intrinsic rhythm becomes too slow or goes away completely, the electronic pacemaker senses that and starts sending out signals along the wires leading from the control box to the heart muscle. The electrical signal produced by pacemaker properly provide a regular electrical stimulus, making the heart contract at a rate fast enough to maintain the patient s blood pressure. Pacemaker Attachment with Heart Muscles Figure 2 Scientech Technologies Pvt. Ltd. 12

13 Pacemaker Pulses: The wave form used for pacing are round-topped rectangular pulses of 1-7 ms duration with rates adjustable from pulses/min. Amplitude and duration (Pulse width) of the pulses can be differ patient to patient and also depends on the type of disease. Ideal Pulses Actual Pulses Figure 3 Pacemaker produced pulses for both triggering and inhibiting depending on mode of working which is previously set by the manufacturer as per discussion with the concerned Doctor. Pulses of pacemaker can be positive or negative going which is previously set by the manufacture, while in ST2361 positive pulses are used for triggering and negative pulses for inhibiting purposes. Shape of actual and ideal pulses slightly differ from each other because of circuit capacitance but these actual pulses are not harmful for the patients. In dual chamber pacing type of pacemaker two triggering pulses are given with little delay of time, just after some time of atrial depolarization. Second pulse is used for triggering the ventricles. Scientech Technologies Pvt. Ltd. 13

14 1. External Pacemaker: Type of Pacemaker External pacemakers are employed to restart the normal rhythm of the heart in case of cardiac standstill, in situation where short term pacing is considered. Frequently external pacemakers are used for patients recovering from cardiac surgery to correct temporary conduction disturbances resulting from the surgery. 2. Internal Pacemaker: Internal Pacemakers are used in cases requiring long term pacing because of permanent damage that prevents normal self triggering of the heart. Programming Modes of Pacemaker: I II III IV V Chamber(s) Paced Chamber(s) Sensed Mode(s) of Response Programmable Functions Anti tachycardia Functions V= Ventricle V=Ventricle T=Triggered R=Rate Modulated A=Atrium A=Atrium I=Inhibited C=Communicati ng O=None P=Paced D=Dual (A&V) D=Dual (A&V) D=Dual Triggered/Inhibi ted M=Multi programmable S=Shocks O=None O=None O=None P=Simple Programmable D=Dual (P&S) O=None NASPE...North American Society of Pacing and Electrophysiology BPEG...British Pacing and Electrophysiology Group Position I: Position I of the code indicates the chamber (or chambers) paced. Since pacing the heart is the primary function of the pacemaker, this function is given position I (one). A device used to pace in only one chamber will be represented by either the letter A (atrial) or V (ventricular) while devices that are capable of pacing in both chambers are represented by the letter D (dual).there is a code letter S that identifies the pacemaker as a single chamber device. This is only used as a manufacturer s designation and is not valid once the pacemaker is attached to a lead. Pacemaker using the manufacturer s designation "S" in the first position may be attached to a lead that has been placed either in the atrium or ventricle. Scientech Technologies Pvt. Ltd. 14

15 Position II: Position II of the code represents the chamber (chambers) used for the sensing function of a pacemaker. The letter designations for position II are the same as the designations for position I. It must be noted however that a device may not be represented by the same letter in both positions. An example of different letter codes in the first two positions is VDD. In this example, the ventricle is the chamber paced but the pacemaker is capable of sensing in both the atrium and the ventricle. Just as in position I, there is a code letter S that identifies the pacemaker as a single chamber device. This is only used as a manufacturer s designation and is not valid once the pacemaker is attached to a lead. Pacemaker using the manufacturer s designation "S" in the second position may be attached to a lead that has been placed either in the atrium or ventricle. Position III: Position III tells us the mode of response to sensing. Position III is directly tied into position II. Without sensing, there can be no mode of response to sensing. When position III is identified as I (inhibited), the mode of response is to withhold a pacemaker output in the presence of a sensed event. In a VVI pacemaker, the pacemaker senses a ventricular event and withholds the ventricular output. If the pacemaker is programmed to the DDI mode, the pacemaker simply inhibits the output of the device in the chamber where any signal is sensed. The letter D (dual) in the third position indicates that the device will respond to the sensed signal by inhibiting the pacemaker response, tracking the sensed event, or inhibiting the output on the sensed channel and triggering an output to maintain AV synchrony. The most common example of the letter D in the 3 rd position can be seen with DDD pacemakers. A sensed atrial signal will cause the device to inhibit the atrial output, a timer then starts that will cause a triggered ventricular output after a certain interval. If the patient has an intrinsic R wave during the triggering interval, the pacemaker will inhibit the ventricular output. Position IV: Position IV tells us something about the programmable parameters of the device. Device can be programmed, and communicate. In the real world, the only letter usually spoken is the letter R (rate response). A patient with a rate responsive DDD pacemaker is said to have a DDDR pacemaker. R (Rate Response) in the 4th position only tells us that the device is capable of (and programmed to) a rate responsive function. It does not describe the type of sensor available in the pacemaker. C (Communicating) tells us that the pacemaker is capable of transmitting and/or receiving data for informational or programming purposes. Most of the devices currently manufactured have a communicating ability. Scientech Technologies Pvt. Ltd. 15

16 M (Multi-Programmable) indicates that the device can be programmed in more than 3 parameters. All DDD pacemakers are also multi-programmable. Typical programmable parameters include rate, sensing, output, refractory periods, mode and hysteresis. Dual chamber pacemaker usually has many more programmable parameters available. P (Simple Programmable) usually indicates that the pacemaker is limited to 3 or fewer programmable parameters. This letter in the 4th position is limited to single chamber devices. Typical simple programmable parameters include: rate, output and sensing. O (None) is rarely encountered and indicates that the device has no programmable parameters. Position V: Position V tells us whether or not the device has any Anti tachycardia features. In the pacemaker only population the fifth position can only be represented by O or P. The device either has no antipathy feature or it can attempt to pace the patient out of a tachycardia episode. The fifth position is used fully by implantable cardioverter defibrillators and their ability to pace or shock patients out of tetchy arrhythmias. Kinds of Pacemaker: Pacemaker can be either temporary or permanent. The temporary pacemakers that we see in the MICU (Medical / Mobile Intensive care unit) are made up of a control box and one single output wire leading to the inner wall of the RV (Right Ventricle) thus called a ventricular wire, or V-wire, and provides simple rate control by pacing the ventricles. Permanent pacemakers come in several flavours, but the main difference between them is that some have only one wire leading to the RV, and some have two wire systems, one to the RA, and another one to the RV. A pacing system that paces both the RA and the RV is called an Atrio-ventricular pacer and paces both right heart chambers in sequence. The signal affects the left-side chambers and stimulates them to contract as well. The signal from the wire generates a visual signal on the ECG that looks like, and is called a spike. One wire system produces only one spike it may be for atria or for the ventricle while two-wire systems generate two spikes, one spike for atria and one for the ventricle. Implantable Pacemaker: The implantable pacemaker, along with its electrodes, is designed to be entirely implanted beneath the skin. Its output leads are connected directly to the heart muscle. The pacemaker is a miniaturized pulse generator and is powered by small batteries. The circuit is so designed that the batteries supply sufficient power for a long time. Since the pacemaker is located just beneath the skin, the replacement of the pacemaker unit involving relatively minor surgery has become a routine procedure. Scientech Technologies Pvt. Ltd. 16

17 For any implanted circuit, the basic requirements are: The component used in the circuit should be highly reliable. The power source should be in position to supply sufficient power to the circuit over prolonged periods of a time. The circuit should be covered with a biological inert material so that implant is not rejected by the body. The should be covered in such a way that the body fluids do not find a way inside the circuit and thus short-circuit the batteries or result in other malfunctioning of the circuit. Trans-Venous, Trans-Cutaneous and Trans-Thoracic Types of Pacemaker: 1 Trans-Venous means that the pacing wire is threaded down the jugular vein through an introducer. The introducer is put in first, like any central neck IV line, and the wire is passed through it until it makes contact with the inner wall of the RV. Then the wire is attached to a generator box and the heart is paced using the wire. 2 Trans-Cutaneous pacing means using external pacing pads connected to a device like the Zoll machine or one of the defibrillators that has external pacing ability. 3 Trans-Thoracic pacing means using wires inserted during cardiac surgery. Small wires that sit on the outer wall of the heart pericardium. Wires that lead out of the chest to a control box or doing manoeuvres that involves pushing a pacing wire into the RV up through the chest wall subxiphoid during a code. Scientech Technologies Pvt. Ltd. 17

18 1 Rate Hysteresis : Hysteresis Rate hysteresis allows the pacemaker to be inhibited at rate lower than programmed basic rate, thus encouraging negative rhythm and possible prolonging device life. 2 AV/PV Hysteresis : The AV Delay is the time interval between an atrial output pulses and the corresponding ventricular output pulses in the absence of intrinsic activity. While PV Delay is the interval between an intrinsic atrial event and the corresponding ventricular pulse in the absence in intrinsic ventricular activity. Both of these are independently programmable. This type of hysteresis available only in DDDR or DDD mode of pacemaker working. An positive AV/PV hysteresis is desired, an AV/PV Hysteresis delta must be programmed which represent the amount of time the AV or PV delay interval will be automatically extended when an inhibiting, intrinsic ventricular event is sensed during an AV/PV delay. Type of Leads and Electrodes: The Electrodes for delivering stimulating pulses can be connected either on the outside or inside wall of the heart. Electrode connected to the outer wall of the heart muscle are called myocardial electrode, electrodes which are connected to the inner side of the heart chamber are known as endocardiac electrodes. Endocardiac electrodes are inserted through suitable vein, preferably the jugular vein and pushed directly into the heart. This method offers an advantage in that open heart surgery is not necessary for the replacement of the myocardial electrode. Suture less Leads: Suture less myocardial leads requires no stab wound or sutures for electrodes placement and support. The electrode of suture less lead is shaped like a cork screw and rotates into the myocardium with two clockwise turns and firmly secured to it. The lead is mounted on special handle for rotation into myocardium. Supplied along with lead is a tunnelled that is used to release the lead conductor and electrode from the handle. Tissue damage from electrodes insertion appears less than that associated with other type of myocardium electrodes, resulting in minimal fibrosis around electrode tip. The electrode has 3.5mm electrode depth penetration. Its surface area is 6.6sq.mm. The large electrode surface area cause fewer sensing problem promotes reliability. The leads length is available as 54 or 35cm. The electrode is formed of platinum (70%) and iridium (30%) which gives it a strong corrosion-resistant surface that resists coil compression and distortion. The electrode's 5mm coil diameter spreads the potential stress over a large surface area and promotes secure attachments of the electrodes with tissue. Bio-compatible silicon-rubber provides sheath to both the electrode lead and the head. An electrode provides two functions in a demand pacemaker. It senses the heart's electrical activity and stimulates the heart. Any displacement in the electrode position manifests itself in a decrease in the R-wave amplitude and a reduced slew rate (rate of change of voltage with time). A typical value of slew rate is 3V/s. In practice, it is Scientech Technologies Pvt. Ltd. 18

19 found that the slew rate is much more sensitive indicator of electrode placement than R-wave amplitude. Pacemaker sensing amplifiers employ band pass filter to discriminate between R-wave and T-wave. A consequence of this that R-wave of smaller slew rate is also attenuated and therefore, it is likely that an R-wave within amplitude exceeding the R-waves (under 5mV) where even moderate attenuation could lead to sensing problems. A sensing electrode has certain impedances associated with it. The degree to which sensing impedance affects pacemaker sensing is dependent on the ratio of the input impedance of the sensing amplifiers to the sensing impedance. Typically, most pacemakers have an input impedance of 20KΩ greater. A leakage path between the pacemakers terminals will be in parallel with the input impedance will lower it. For example, a leakage path of 2KΩ between terminals will result in 1800Ω. A small surface area electrode with a sensing impedance of 2KW will create R-wave attenuation 58%. Therefore, small surface area electrodes having larger sensing impedance will have minimal effect in case input impedance of amplifier is high and the leakage is negligible. 1 Porous Tip Electrode : It provides a high stability lead for the endocardiac method of pacemaker implant. The porous lead has an % porous platinum-iridium tip that stabilizes the porous quickly with little endocardiac irritation. 2 Steroid-eluting Electrodes : These electrodes have evolved fro large surface area (30-40mm 2 ) than other electrodes. In order to stimulate the heart an important consideration is density of the current at the electrode tissue interface and this is influenced by several factors such as surface area of electrode, amount of fibrotic encapsulation, electrical material, pulse width and pulse amplitude. Pacemaker Electrode System: Two types of electrode systems are commonly used, bipolar and unipolar. In the unipolar system, one electrode (indifferent electrode) is usually a large metal plate attached to the pulse generator. The indifferent electrode is much larger in size than the pacing electrode. The current in this case flows between the pacing electrode in the heart and indifferent electrode via the body tissue. The batteries are so arranged that the pacing electrode is negative (cathode) and indifferent electrode is positive. In the bipolar electrode system, both electrodes are approximately of the same size and both are placed inside or on the heart, so that the current flows between the electrodes. The pulse generator is so attached that the distal electrode, at the tip of the catheter, is negative and the proximal electrode ring is positive. Both the unipolar and bipolar configuration has advantages and disadvantages. A typical unipolar lead used for permanent stimulation of the heart consists of two parts: the electrode and the lead. The proper negative heart electrode is represented by the platinum-iridium (Pt- Ir) catheter tip and has a length of 2mm and diameter of 3mm. The tip is connected to a connecting lead; a Pt-Ir specially wound wire completely embedded in silicon rubber. The outer diameter of the lead is 3mm and its length is about 125cm. The silicon-rubber core in the spiral gives the lead an excellent mechanical sturdiness. The indifferent electrodes are usually made up of stainless steel whereas it is desirable to Scientech Technologies Pvt. Ltd. 19

20 make the active electrode from the Platinum-Iridium alloy to avid damage which may be caused due to electrolysis by body fluids when used over a long periods. Once the pulse generator and the leads are place, electrode tip which comes in contact with the Endocardium and myocardium creates a dynamic process involving physiological changes at the electrodes. A fibrous tissue encapsulates the electrode which increases the simulation threshold. This process is continues for approximately for one month during which period, the electrodes stabilizes within the fibrous capsule. The increased threshold is due to reduced current density in the most immediate active heart cells. As a result, significantly more efficient electrodes have been developed. The optimal electrode surface is around 11sq.mm. Failure to sense: Remember, the pacemaker has both a sensing circuit and an output or pacing circuit. The pacer has to sense whether or not the patient is generating a rhythm so it will know when to pace and when not to. In this case the pacemaker will generate spikes that do capture but the spikes come at the wrong time and the box is clearly unable to see what the patient s heart is doing. Clearly a bad thing it can result in the infamous R-on-T situation, producing VT or VF. Scientech Technologies Pvt. Ltd. 20

21 Operating Instructions 1. While studying different wave s configuration, lead selection switch should be on correct position to get the desired wave shape. 2. Properly connect the patch cord to get the corrected wave after pacemaker action. 3. Initial five diseased waves are related to the single chamber pacing/sensing of atria only 4. 6 th, 7 th and 8 th waves are related with the ventricles pacing and sensing only th and 10 th waves are related with the dual chamber pacing/sensing. Scientech Technologies Pvt. Ltd. 21

22 Pacemaker Waves Diagram Normal Sinus Rhythm Bradycardia Corrected Bradycardia Tachycardia Corrected Tachycardia Atrial Flutter Corrected Atrial Flutter Scientech Technologies Pvt. Ltd. 22

23 Atrial Fibrillation Corrected Atrial Fibrillation Junctional Rhythm Corrected JR Premature Ventricular Contraction Corrected PVC Ventricular Tachycardia Corrected VT Scientech Technologies Pvt. Ltd. 23

24 Ventricular Fibrillation Corrected VF II AV Block Corrected II AV Block III AV Block Corrected III AV Block Figure 4 Scientech Technologies Pvt. Ltd. 24

25 Experiment 1 Objective: Study of Normal Sinus Rhythm (Lead II) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select Normal Sinus Rhythm Using Selection Switch Observation: 1. Observe the Normal Sinus Rhythm at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Normal Sinus Rhythm with the standard shape given in the manual Conclusion: Normal Sinus Rhythm 1. Normal Sinus Rhythm wave is observed with appropriate shape Figure The Presence of all (P, Q, R, S, T and U) waves give the indication of standard (Lead II) Normal Sinus Rhythm 3. Amplitude and frequency of all other waves (P, Q, R, S, T and U) are same as in standard Lead II Configuration of ECG Questions: 1. Classify the Cardiac Rhythm Diagnosis? 2. Give the frequency range of sinus rhythm? Scientech Technologies Pvt. Ltd. 25

26 Experiment 2 Objective: Study of Bradycardia (Slower Heart Rate < 60) Equipments Needed: 1 Pacemaker Simulator ST mm Patch cord 3 Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4 Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select Bradycardia Using Selection Switch Observation: 1. Observe the Bradycardia wave at output terminal. 2. Observe the each Systolic action of the Heart by LED/Buzzer indication. 3. Compare the Bradycardia wave shape with the Standard shape given in the manual. Conclusion: Bradycardia 1. Bradycardia wave is observed with appropriate shape. Figure Presence of long delay between two successive T waves giving the indication of Bradycardia. 3. Long delay along with the approximately normal wave shape indicates Bradycardia. Questions: 1. What is sinus Bradycardia? 2. When does the heart rate increase or decrease? Scientech Technologies Pvt. Ltd. 26

27 Experiment 3 Objective: Study of Corrected Bradycardia wave (Pacemaker Action). Equipments Needed: 1 Pacemaker Simulator ST mm Patch cord 3 Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4 Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Connect the electrode and heart atrial terminals using 2mm patch cord Observation: 1. Observe the Corrected Bradycardia wave at output terminal. 2. Observe that each Systolic action of the Heart by LED/Buzzer indication. 3. Compare the Corrected Bradycardia with the Standard shape given in the manual. Corrected Bradycardia Conclusion: 1 Corrected Bradycardia wave is observed with appropriate shape Figure Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action 3 Presence of normal delay between two successive R waves giving the indication of again Normal Sinus Rhythm Questions: 1. What is sinus Bradycardia? 2. Give the frequency range of sinus rhythm? 3. What do you understand by sinus rhythm? Scientech Technologies Pvt. Ltd. 27

28 Experiment 4 Objective: Study of Tachycardia (Faster Heart Rate > 100) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1 Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2 Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4 Select Tachycardia Using Selection Switch Observation: 1 Observe the Tachycardia wave at output terminal 2 Observe the each Systolic action of the Heart by LED/Buzzer indication 3 Compare the Tachycardia with the Standard shape given in the manual Conclusion: Tachycardia 1 Tachycardia wave is observed with appropriate shape. Figure Presence of very short delay between two successive R waves giving the indication of Tachycardia. 3 P wave appears just after the appearance of T wave which conform Tachycardia. Questions: 1. What is the amplitude of R Wave? 2. What is the amplitude of T Wave? 3. What is the amplitude of P wave? Scientech Technologies Pvt. Ltd. 28

29 Experiment 5 Objective: Study of Corrected Tachycardia Wave (Pacemaker Action) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Connect the electrode and heart atrial terminals using 2mm patch cord Observation: 1. Observe the Corrected Tachycardia wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Corrected Tachycardia with the Standard shape given in the manual Conclusion: Corrected Tachycardia 1. Corrected Tachycardia wave is observed with appropriate shape. Figure Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action 3. Pacemaker pulse is inverted in shape shows inhibiting function of the pacemaker 4. Presence of normal delay between two successive R waves again giving the indication of normal sinus rhythm Questions: 1. What is sinus tachycardia? 2. Explain the working of pacemaker? 3. Give the frequency range of sinus rhythm? Scientech Technologies Pvt. Ltd. 29

30 Experiment 6 Objective: Study of Atrial Flutter (Impulse Travels in Circular course in atria) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select Atrial Flutter Using Selection Switch Observation: 1. Observe the Atrial Flutter wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Atrial Flutter with the standard shape given in the manual Conclusion: Atrial Flutter 1. Atrial Flutter wave is observed with appropriate shape Figure Presence of abnormal up-word and down-word in P waves giving the indication of Atrial Flutter 3. Presence of negative polarity of T wave confirms the atrial flutter Questions: 1. What is the phenomenon of junctional rhythm? 2. What is the amplitude of T Wave? Scientech Technologies Pvt. Ltd. 30

31 Experiment 7 Objective: Study of Corrected Atrial Flutter (Pacemaker Action) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Connect the electrode and heart atrial terminals using 2mm patch cord Observation: 1. Observe the Corrected Atrial Flutter wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Corrected Atrial Flutter with the shape given in the manual Conclusion: Corrected Atrial Flutter 1. Corrected Atrial Flutter is observed with appropriate shape. Figure Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action 3. Presence of little normal shape of P wave and reduction of negative amplitude in inverted T wave giving the indication of Corrected Atrial Flutter. 4. Reduced amplitude of S wave shows less ventricular depolarisation because of strong electrical potential in atria. Questions: 1. What is the frequency range of atrial flutter? 2. What is the amplitude of S Wave? Scientech Technologies Pvt. Ltd. 31

32 Experiment 8 Objective: Study of Atrial Fibrillation (Impulses have chaotic, random pathways in atria). Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select Atrial Fibrillation Using Selection Switch Observation: 1. Observe the Atrial Fibrillation wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Atrial Fibrillation with the Standard shape given in the manual Conclusion: Atrial Fibrillation 1. Atrial Fibrillation wave is observed with appropriate shape. Figure Presence of abnormal up-word and down-word in P waves and T wave and no synchronization between two successive P or T wave, indication of Atrial Fibrillation. 3. Atrial depolarization and ventricular repolarization are not having the correct sequence and strength. Questions: 1. Due to what reason atrial fibrillation occurs? 2. What should be the dimensions of P wave? Scientech Technologies Pvt. Ltd. 32

33 Experiment 9 Objective: Study of Corrected Atrial Fibrillation (Pacemaker action) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Connect the electrode and heart atrial terminals using 2mm patch cord Observation: 1. Observe the Corrected Atrial Fibrillation wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Corrected Atrial Fibrillation with the standard shape given in the manual Conclusion: Corrected Atrial Fibrillation 1 Corrected Atrial Fibrillation wave is observed with appropriate shape. Figure Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action 3 Presence of little normal shape of P wave and reduction of negative amplitude in inverted T wave give the indication of Corrected Atrial Flutter. Questions: 1. Due to what reason atrial fibrillation does occur? 2. What do you understand by atrial flutter? Scientech Technologies Pvt. Ltd. 33

34 Experiment 10 Objective: Study of Junction rhythm (Impulses originated at AV node with retrograde and ante grade direction) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select Junction Rhythm Using Selection Switch Observation: 1. Observe the Junction Rhythm wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Junction Rhythm with the standard shape given in the manual Conclusion: Junctional Rhythm 1. Junction Rhythm wave is observed with appropriate shape. Figure Absence of P wave along with large delay between two successive R waves giving the indication of Junction Rhythms. 3. Junction Rhythms are the indication of the diverse direction of electrical voltages at the AV node. Questions: 1. What should be the dimension of P wave? 2. What are the characteristics of P wave? Scientech Technologies Pvt. Ltd. 34

35 Experiment 11 Objective: Study of Corrected Junction rhythm (Pacemaker Action) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1 Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2 Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4 Connect the electrode and heart atrial terminals using 2mm patch cord Observation: 1 Observe the Corrected Junction Rhythm wave at output terminal 2 Observe the each Systolic action of the Heart by LED/Buzzer indication 3 Compare the Corrected Junction Rhythm with the shape given in the manual Conclusion: Corrected Junction rhythm 1. Corrected Junction Rhythm wave is observed with appropriate shape Figure Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action 3. Presence of little normal shape of P wave with positive amplitude in T wave giving the indication of Corrected Atrial Flutter Questions: 1. What is the phenomenon of junctional rhythm? 2. What is the amplitude of T Wave? 3. What is the amplitude of P wave? Scientech Technologies Pvt. Ltd. 35

36 Experiment 12 Objective: Study of Premature Ventricular Contraction (A Single Impulse Originate at Right Ventricle). Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select Premature Ventricular Contraction Using Selection Switch Observation: 1. Observe the Premature Ventricular Contraction wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Premature Ventricular Contraction with the shape given in the manual Conclusion: Premature Ventricular Contraction Figure Premature Ventricular Contraction wave is observed with appropriate shape. 2. Presence of additional large waves after the ventricular repolarization giving the indication of Premature Ventricular Contraction. 3. Because of Presence of this additional wave there is an increase of time duration between two successive R waves. Questions: 1. What is the amplitude of R Wave? Scientech Technologies Pvt. Ltd. 36

37 Experiment 13 Objective: Study of Corrected Premature Ventricular Contraction (Pacemaker Action) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Connect the electrode and heart ventricular terminals using 2mm patch cord Observation: 1. Observe the Corrected Premature Ventricular Contraction wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Corrected Premature Ventricular Contraction with the shape given in the manual Conclusion: Corrected Premature Ventricular Contraction 1 Corrected PVC wave is observed with appropriate shape Figure Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action Questions: 1. Explain the working of pacemaker? 2. What pulse rate is used for pacemaker? Scientech Technologies Pvt. Ltd. 37

38 Experiment 14 Objective: Study of Ventricular Tachycardia (Impulse Originated at Ventricular Pacemaker) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select Ventricular Tachycardia Using Selection Switch Observation: 1. Observe the Ventricular Tachycardia wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Ventricular Tachycardia with the standards shape given in the manual Conclusion: Ventricular Tachycardia 1. Ventricular Tachycardia wave is observed with appropriate shape Figure Presence of incomplete QRS Complex and negative T wave projections giving the indication of Ventricular Tachycardia Questions: 1. What indicates abnormal ventricular activation? 2. What is duration criterion for the QRS-complex bundle-branch block? 3. What normal T waves represents? Scientech Technologies Pvt. Ltd. 38

39 Experiment 15 Objective: Study of Corrected Ventricular Tachycardia (Pacemaker Action) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Connect the electrode and heart ventricular terminals using 2mm patch cord Observation: 1. Observe the Corrected Ventricular Tachycardia wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Corrected Ventricular Tachycardia with the standard shape given in the manual Conclusion: Ventricular Tachycardia Figure Corrected Ventricular Tachycardia wave is observed with appropriate shape. 2 Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action Questions: 1. What is ventricular tachycardia? 2. What is ventricular fibrillation? Scientech Technologies Pvt. Ltd. 39

40 Experiment 16 Objective: Study of Ventricular Fibrillation (Chaotic Ventricular depolarization) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select Ventricular Fibrillation Using Selection Switch Observation: 1. Observe the Ventricular Fibrillation wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Ventricular Fibrillation with the standard shape given in the manual Conclusion: Ventricular Fibrillation 1 Ventricular Fibrillation wave is observed with appropriate shape. Figure Total absence of auricular and ventricular synchronization giving the indication of Ventricular Fibrillation. 3 Because of chaotic ventricular depolarization atrial depolarization and repolarization are also disturbed. Questions: 1. What indicates abnormal ventricular activation? Scientech Technologies Pvt. Ltd. 40

41 Experiment 17 Objective: Study of Corrected Ventricular Fibrillation (Pacemaker Action) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Connect the electrode and heart ventricular terminals using 2mm patch cord Observation: 1. Observe the Corrected Ventricular Fibrillation wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the Corrected Ventricular Fibrillation with the shape given in the manual Conclusion: Corrected Ventricular Fibrillation 1. Corrected Ventricular Fibrillation is observed with appropriate shape. Figure Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action 3. After pacemaker action ventricular depolarization comes in the action. Questions: 1. What is ventricular fibrillation? 2. What is the cause of ventricular fibrillation? Scientech Technologies Pvt. Ltd. 41

42 Experiment 18 Objective: Study of II Degree AV Block (Sudden drop of QRS Complex) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply, then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Select II Degree AV Block Using Selection Switch Observation: 1. Observe the II Degree AV Block wave at output terminal 2. Observe the each Systolic action of the Heart by LED/Buzzer indication 3. Compare the II Degree AV Block with the shape given in the manual Conclusion: II Degree AV Block Figure II Degree AV Block wave is observed with appropriate shape. 2. Total absence of QRS complex giving the indication of II Degree AV Block. Questions: 1. What is the amplitude of QRS Complex? 2. What QRS complex represents? 3. What is the duration of QRS wave? Scientech Technologies Pvt. Ltd. 42

43 Experiment 19 Objective: Study of Corrected II Degree AV Block (Pacemaker Action) Equipments Needed: 1. Pacemaker Simulator ST mm Patch cord 3. Oscilloscope (DS1102C 100 MHz, 400MSa/s) or Equivalent. 4. Computer with Windows 98/2000/Me/Xp operating system Procedure: 1. Connect one end of the power supply to Pacemaker Simulator ST2361, while other end to mains power supply 2. Switch ON the Mains power supply and then ST Connect one end of USB Cable to Trainer while other end to PC USB Port 4. Connect the electrode and heart (atrial + ventricular) terminals using 2mm patch cord Observation: 1. Observe the Corrected II Degree AV Block wave at output terminal. 2. Observe the each Systolic action of the Heart by LED/Buzzer indication. 3. Compare the Corrected II Degree AV Block with the shape given in the manual. Conclusion: Corrected II Degree AV Block 1. Corrected II Degree AV Block wave is observed with appropriate shape. Figure Presence of pacemaker pulse at the initial of wave is the indication of pacemaker action 3. Again presence of QRS complex is the indication of Corrected II Degree AV Block wave. Questions: 1. Why QRS-complex is of relatively short duration? Scientech Technologies Pvt. Ltd. 43