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Heart Blocks and Pacing
PDN Julie Allen SN Solon Avanzado The Queen Elizabeth Hospital King’s Lynn
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PQRST in Normal Sinus Rhythm
Explanation of NSR, ask group to come up with what is happening at each point – useful to draw diagram with conduction system
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Conduction system
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FIRST Look at the patient!
Convey the importance of the patients condition and troubleshooting ie not assuming asystole when leads are off!
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Arrhythmias – at a glance!
Patient? – poorly or well Rate? – Too fast or too slow Complexes? – Narrow or Wide Treatments? Drugs or electricity Simplified assessment process
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Heart Blocks Block in normal conduction
Could be at any part of the conduction system Ranging in severity Transient or permanent Can deteriorate May require pacing Introduction to heart blocks
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1st Degree Block Ask the students what they see. Explain characteristics, possible causes, effects on the patient, appropriate management
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2nd Degree Block Mobitz Type 1: Wenckebach
Ask the students what they see. Explain characteristics, possible causes, effects on the patient, appropriate management
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2nd Degree Block Mobitz Type II
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Complete Heart Block Ask the students what they see. Explain characteristics, possible causes, effects on the patient, appropriate management
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Pacing Temporary – Permanent – Implanted device
Transcutaneous (Emergency use with external pacing/defib unit, precordial thump!!!!!) Transvenous (Emergency use with external pacemaker) Permanent – Implanted device
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Indications for Temporary
Bradycardia with unstable haemodynamics unresponsive to Atropine. Bradycardia with symptomatic escape rhythms unresponsive to medication. PEA - overdose, electrolyte abnormalities, acidosis Over ride pacing – refractory tachycardias (failed cardioversion or medication) Inferior MI with Heart Block
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Contraindications to temporary pacing
Severe hypothermia Prolonged bradyasystolic arrest
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Types of pacing box Single Chamber Dual Chamber
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Indications for permanent
• Symptomatic CHB CHB that does not recover following: - MI after 2 weeks - Valve replacement after 1 week - CABG after 2 weeks Bifascicular block, BBB or CHB post anterior infarct Symptomatic sinus arrest or AV block not related to drugs
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Permanent Pacing Single/Dual chamber Pacing and defibrillate
Magnets and MRI scanners
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Atrial pacing Indications : • Sinus bradycardia
• Supression of ventricular ectopics • Slow junctional rhythms • Overdrive pacing of supra-ventricular tachycardias NB – atrial pacing is ineffective in atrial fibrillation and fluter
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Atrio-ventricular pacing (Sequential pacing)
Indications : • Complete block • Second degree block to achieve 1:1 conduction • First degree block if PR interval too long AV pacing is always preferable to single chamber pacing.
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Ventricular pacing Indications :
• Slow ventricular response to atrial fibrillation/flutter • Failure of atrial pacing to maintain heart rate NB – ventricular pacing is the least effective mode for optimising haemodynamics.
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Pacing Modes Fixed rate:
Pacing Mode stimulates the heart at a pre-set interval Does not respond to intrinsic heart activity !!Fixed ventricular pacing can trigger VT/VF!!
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Pacing Modes Demand: Pacemaker initiates an impulse only when a pre-set R-R interval has elapsed without spontaneous cardiac activity The escape interval is determined by the rate the pacemaker is set The pacemaker is inhibited by intrinsic cardiac activity
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Complications Permanent Temporary Pneumothorax Pericardial effusion Infection – endocarditis Hematoma Wire displacement Avoid placing defibrillator pads directly over permanent pacing devices Transvenous – All the same as Permanent with increased risk of wire displacement Transcutaneous – Poor contact resulting in non-pacing Skin burns (abrasions, prolonged usage without changing pads regularly)
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Other issues with permanent
MRI scanning – myth that unable to go in MRI Travel – Pacemaker cards are carried for travelling through security. Driving – 1 week after implantation for ordinary (Group1) 6 weeks for vocational (Group 2) Batteries years depending upon usage. MRI 1.5% of 438pts & 500 scans resulted in heart device to reverting to default settings . Circulation 2006; 114 (12):
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Analysis of Pacing Problem
Need to obtain rhythm strip or 12 lead ECG Establish pacemaker settings (if possible) If there are pacing spikes with no corresponding P-QRS = pacing/capture problem If there are no pacing spikes where you would expect them = sensing problem
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Atrial pacing, Ventricular pacing, failure to capture, failure to sense
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Nursing Care Transcutaneous Transvenous Explain to patient
Skin prep – trim hair, dry skin Good skin contact – avoid electrodes & transdermal patches Avoid carotid pulse check use femoral Pain relief & sedation Monitor & record Hr rate & rhythm Monitor & record pacing (rate, current output, mode) Monitor & record Hr, B/P & rhythm to assess response Observe sensing of intrinsic beats & appropriate device pacing Secure wire and device – extreme care with confused patients Immobility - bedrest
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