Presented By: Barbara Furry, RN-BC, MS, CCRN, FAHA Director The Center of Excellence in Education Director of HERO Follow me on Twitter! CEE Med Updates@BarbaraFurryRN Like me on Facebook! 1
A. Atropine 0.5mg IV B. Transcutaneous pacemaker C. Epinephrine 1mg IV D. Dobutamine 2-10mcg/kg per min 77% 15% Atropine 0.5mg IV Transcutaneous pacemaker Epinephrine 1mg IV 8% 0% Dobutamine 2 10mcg/kg pe... 2
Transcutaneous pacing (TCP) electrical stimulation from electrode pads to induce cardiac depolarization Rapid, safe and non invasive Increase HR and improves cardiac output Short periods Therapeutic bridge 3
Electrical concepts Electrical circuit Pacemaker to patient, patient to pacemaker Current- the flow of electrons in a completed circuit Measured in milliamperes (ma) Voltage a unit of electrical pressure or force causing electrons to move through a circuit Measured in millivolts (mv) Impedance- the resistance to the flow of current 7 Symptomatic sinus bradycardia, sinus arrest, or brady-tachy syndrome Mobitz II second- and third-degree heart block Symptomatic AF with slow ventricular response Escape rhythms not responding to drug therapy BBB in the setting of AMI New-onset left bundle branch block Right bundle branch block with left axis deviation Bifascicular block Alternating bundle branch block 4
Noninvasive pacing can be used when invasive pacing is undesirable, e.g., in patients with the potential for excessive bleeding, such as those receiving fibrinolytics Where there is increased potential for infection, as in patients with a suppressed immune system or systemic infections Or where placement of a temporary wire might be difficult, such as in patients with tricuspid valve prosthesis Noninvasive pacing should be used on standby in situations when the patient is clinically stable yet may quickly decompensate or become unstable Patients who may benefit from standby pacing include: Cardiac patients undergoing surgery Patients with acute MI and signs of early heart block Patients needing surgery for permanent pacemaker implantation Pulse generator change, or lead wire replacement Patients undergoing cardiac catheterization or angioplasty, and those with risk of developing postcardioversion bradycardias 5
Awake, hemodynamically stable patients Severe hypothermia Non-intact skin at the site of pacemaker pad placement (burns) ECG monitor/defibrillator/pacer ECG electrodes and pacing pad Resuscitation supplies Drugs for sedation & analgesia 6
Pacer pads Skin cleaned, dried and clipped Anterior Posterior sandwiches Anterior pad: just to the left of the sternum or below the left breast Posterior pad: to the left of the spine, just below the inferior pole of the left scapula 7
Anterolateral Right anterior pad: right of the sternal margin, at the second or third intercostal space Left lateral pad: left fourth or fifth intercostal space, at the midaxillary line Set The Machine Mode: Fixed (asynchronous) Demand (synchronous) avoids electrical impulse output during the repolarization phase which could cause VT/VF Rate Set the rate 20 above patient intrinsic rate If no intrinsic rate, set to 100 8
Energy Pacemaker initial output of 0 ma Increase the output until each pacer spike is followed by a wide QRS complex (electrical capture) Decrease the output ma to maintain capture at the lowest possible energy In cardiac arrest start at max energy and decrease the output after capture is achieved Refers to the successful stimulation of the myocardium (by the pacemaker impulse) that results in depolarization Evidenced on EKG by a pacemaker spike followed by a wide ventricular complex 9
Patients can achieve capture at 50 to 90 ma but individual thresholds vary Capture thresholds are not related to body surface area or weight Related to recent thoracic surgery, pericardial effusion, pericardial tamponade, hypoxia, acidosis and other physiological variable may lead to higher capture thresholds Pacemaker has delivered a pacing stimulus that was unable to initiate depolarization of the myocardium and subsequent myocardial contraction Evidenced on EKG by pacemaker spikes that are not followed by a QRS complex for ventricular pacing 10
Loss of Capture Assess the patient Quality of pulse Observe for signs of improved cardiac output mental status, blood pressure and pulse ox Evaluate pads every 30 minutes to avoid skin burns and change place after few hours 11
Assure adequate sedation and analgesia if hemodynamics allows Treat arrhythmia & plan for invasive pacing if medical intervention is not successful Failure to detect VF VF/VT Pain Skin burns Failure to capture Failure to pace Hiccups 12
Sensing is the ability of the demand pacemaker to identify electrical activity which stems from the myocardium Undersensing occurs when the pacemaker does not sense intrinsic activity, and delivers a pace pulse To correct undersensing select a different lead or reposition the ECG electrodes These troubleshooting measures focus on changing the appearance of the ECG signal to the monitor in order for proper sensing to occur Skin preparation may need to be repeated and new ECG electrodes applied 13
Oversensing is inappropriate inhibition of a demand pacemaker due to detection of signals other than R waves, such as muscle artifact or T waves When oversensing occurs the pacemaker will not maintain the set rate. The actual pace rate will lag behind the set pace rate If oversensing persists, change to a different ECG lead or reposition the ECG electrodes 86% A. Yes B. No 14% Yes No 14
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The typical patient who benefits from noninvasive pacing is one with a primary conduction disturbance or transient disorder such as a post-cardioversion bradycardia or bradycardia secondary to drug toxicity Pacing is less likely to benefit patients who have been in prolonged cardiac arrest or have extensive myocardial damage or cardiac trauma Early intervention is key! 17
In Conclusion Noninvasive pacing will not convert rhythms such as ventricular fibrillation, atrial fibrillation or atrial flutter Noninvasive pacing is a valuable therapy in emergency cardiac care. The basic principles of invasive pacing apply to noninvasive pacing Noninvasive pacing allows rapid initiation of emergency pacing and buys time to stabilize the patient and plan further care 18