1. Cardiovascular Therapeutic Management 2013
MS II

2. Objectives
Describe the functions of a temporary pacemaker and an implantable cardioverter-defibrillator.
(continued)

3. Temporary Pacemakers
Electronic devices used to initiate the heartbeat when the heart’s intrinsic rhythm cannot effectively generate a rate adequate to support cardiac output
Uses
Temporarily
Supportively
Prophylactically
Permanently
Duration – until the condition responsible for the rate or conduction disturbance resolves.

4. Indications Bradydysrhythmias Tachydysrhythmias Causes Drug toxicity
Acute MI
Acute Coronary Syndromes
Following cardiac surgery

5. Pacemaker System
Simple electrical circuit consisting of a pulse generator and a pacing lead with one, two or three electrodes.
Pulse generator is designed to generate an electrical current that travels through the pacing lead and exits through an electrode (exposed portion of the wire) that is in direct contact with the heart.
The electrical current initiates a myocardial depolarization.
The current returns to the pulse generator to complete the circuit.
Power source is a 9-volt alkaline battery

6. Pacing Lead Systems
FIGURE 13-1 The Components of a Temporary Bipolar Transvenous Catheter. A, Singlechamber temporary (external) pulse generator. B, Bridging cable. C, Pacing lead. D, Enlarged view of the pacing lead tip. (A, Courtesy Medtronic Inc., Minneapolis, Minn.)

7. Pacing Routes Transcutaneous use of two large skin electrodes
One placed on the anterior chest the other on the posterior chest
These are connected to an external pulse generator
Rapid, noninvasive procedure
First line intervention that nurses can initiate in the ACLS algorithm – for the treatment of symptomatic bradycardia
Used as an emergency short-term therapy until the situation resolves or another route of pacing can be established

8. Epicardial Pacing
Insertion of temporary epicardial pacing wires is a routine procedure during most cardiac surgical cases
Ventricular and in some case atrial pacing wires are loosely sewn to the epicardium.
The terminal wires are pulled through the skin before the chest is closed.
These are removed several days after surgery by gentle traction at the skin surface with minimal bleeding risk

9. Transvenous Pacing http://rnbob.tripod.com/transven.htm
Temporary – transvenous endocardial pacing is accomplished by advancing a pacing electrode wire through the subclavian or internal jugular and into the right atrium or right ventricle.
Insertion
Fluoroscopy
Through a pacing swan
Through a central line cordis

11. Pacing Modes
Synchronous – pacemaker only delivers a stimulus when the heart’s intrinsic pacemaker fails to function at a predetermined rate.
Atrial/Ventricular Pacing
Most physiologic
Mimics the sequential relationship between the atrium and the ventricle
Increases cardiac output

12. Pacing Modes Asynchronous pacing Fixed rate
Ignores the patient’s intrinsic rate
Used in emergencies when the patient is in asystole as a life saving measure
Sometimes used in the operating room when electromagnetic interference from electrocautery and other electrical equipment can interferer with normal pacemaker function.

13. Nursing Care of the patient with an emergent pacemaker
Continuous ECG monitoring – patent IV access (two sites at least)
Set monitor on pacing to sense pacer energy or spikes
Assess vitals regularly depending on patient status
Assess perfusion – check a radial pulse while watching the monitor. Does the pacer spike generate a pulse
Reassure the patient
Provide pain medication/sedation for a patient with transcutaneous pacing
Prepare for transfer or for transvenous pacing/permanent pacer insertion depending on the setting.

14. Permanent Implanted pacemaker
Paces the atrium and the ventricle

15. Nursing Care of the patient with a pacemaker
Prevention of pacemaker malfunction
Assessment – ECG monitoring
Secure pacing leads and bridging cable to the body
Secure the external pulse generator
Have extra batteries available
Securing pacing leads and bridging cable to the body, reassess this with position changes, ambulation. The external pulse generator can be placed on the patient’s waist or placed in a telemetry bag. For the patient on bedrest the pulse generator can be suspended with twill tape from an Iv pole mounted overhead on the ceiling

16. Stray electricity Protecting against micro-shock
Even a small amount of stray electrical current from other equipment can precipitate ventricular fibrillation a lethal arrhythmia
Nurses should wear rubber gloves – non-latex variety when caring for the patient
Cover terminal pacing pins with caps or gloves as well
Use a non-electric grounded bed
Keep all electrical equipment away from the bed
Only rechargeable electric razors

17. Pacemaker Problems Failure to Capture Failure to Pace Undersensing
See page 222
Failure to Pace
Undersensing
Oversensing

18. Risk for infection Assess site for s/s of infection – manifested by
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Endocarditis is a risk for a patient with epicardial pacing wires in place

19. Myocardial Perforation
Very rare but can occur
Symptoms
Rhythmic hiccoughs
Cardiac Tamponade
Review symptoms of cardiac tamponade – falling arterial pressures, narrowing pulse pressure, muffled heart sounds, shock.

20. Patient education temporary pacemakers
Instruct the patient to not handle the exposed portion of the lead wire.
Notify the nurse if the dressing over the insertions site becomes soiled, wet, or dislodged.
Done use any electrical devices brought in from home that could interfere with pacemaker function.
Restrict movement of the affected extremity to avoid displacement.
I-Pods are big culprits for pacemaker malfunction, electric appliances need to be disconnected and used with the battery on.