Pacemaker Malfunctions

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Pacemaker Malfunctions

• Even less amusing!

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Pacemaker Codes (NASPE/BPEG)
Position I II III Category Ch
amber(s) Chamber(s) Response to
paced sensed sensing ONone
ONone ONone AAtrium
AAtrium Ttriggered VVentricle
VVentricle IInhibited DDual (AV)
DDual(AV) DDual (TI)
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Triggered

• Means different things
• If an intrinsic event is sensed, the pacemaker
  will trigger pacing to that chamber OR to another
  chamber
• P wave will trigger an AV interval
• R wave will trigger pacing to the ventricle

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Triggered?
Atrial paced spike triggers AV interval
Triggered ventricular pacing spike is in
refractory period of ventricular cycle
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AOO Pacing
Asynchronous mode Not sensing so cant react
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VVI Pacing
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Even more!

• Fourth letter-Programmable Functions
• R rate modulation
• C Communicating
• M Multiprogrammable
• S simple programmable
• O None

• Fifth letter antitachycardic functions
• O none
• P paced
• S shock

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Rate Modulation

• Atrium or Ventricle is pacing or tracking above
  the set upper limit (permanent pacemaker)
• Used to help compensate for increased demands
• Sensor can be
• Change in temperature
• Change in movement or body position
• Change in pH
• Change in minute ventilation

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DDDR Pacing
Chamber Paced
Chamber Sensed
Response to a Sensed Event
Rate modulated
D D D R
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Pacing Malfunctions

• Often a two person job
• One person supports the patient
• One person troubleshoots the pacemaker

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Failure to pace (not tryin to tickle)

• No pacing spikes or not enough coupled with the
  intrinsic rhythm to ensure good CO

• Pacing energy not being transmitted from
  generator to patient

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Failure to pace ( not trying to tickle)
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How do you fix this?

• Pacing spikes not visible (often an equipment
  problem)
• Pacer on?
• Rate set correctly?
• Battery fresh ?
• Connections tight?
• Get another cable
• Get another generator
• Often an equipment problem-no energy thrown

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Failure to capture (target is not ticklish/not
ticklin hard enough)

• Pacing Arm is throwing out energy-target is not
  responding

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Loss of Capture (target is not ticklish)
Nothing happens in response to arm throwing out
impulse
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How do you fix this?

• Myocardium is not responding to stimulation
• Battery fresh?
• Connections tight?
• Make sure lead is in contact with myocardium
• mA high enough?
• Assess electrolytes, oxygenation, acid base
  balance
• Ischemic tissue? Fibrin sleeve?
• Reposition patient or patients arm on side of
  pacemaker if subclavian entry

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Undersensing (ticklin too much)

• Intrinsic rhythm not seen so pacing arm throws
  out energy

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Undersensing (ticklin at the wrong time)
Pacer eyeball is set too high! Cant see target
moving so the arm throws out a stimulus
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The danger of not seeing...
Pacer arm throws out stimulus during
vulnerable portion of cardiac cycle
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How do you fix this

• Pacermaker not seeing correctly
• Battery fresh
• Connections tight
• Leads in contact with myocardium
• Lead fracture
• Do a sensitivity threshold to get eyes at proper
  level

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Oversensing ( not ticklin enough)

• Pacemaker misinterprets noncardiac events as
  intrinsic activity

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Oversensing (not ticklin enough)
Pacer eyeball thinks it sees cardiac activity so
the arm does not throw out an stimulus
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How do you fix this

• Pacermaker not seeing correctly
• Battery fresh
• Connections tight
• Leads in contact with myocardium
• Lead fracture
• Do a sensitivity threshold to get eyes at proper
  level

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Lets practice
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Other Complications

• Infection
• Pulmonary embolus
• Venous Thrombus
• Myocardial perforation
• Endocarditis

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Nursing Care

• Assess heart rate and rhythm
• Protect patient from injury
• Troubleshoot malfunctions
• Evaluate pacemaker function
• Keep patient informed

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Sample documentation

• Temporary pacemaker (0800)
• Epicardial wires ( 2 ventricular)
• Pacing threshold 3 mA set at 6
• Sensitivity threshold 4 mV mV set at 2 mV
• Rate set at 60 patients intrinsic rate 30
• Patient pacing about 50 of time. 100 capture
  when paced.
• Temporary pacemaker (1400)
• Pacemaker off. Pacing wires grounded and taped
  to chest wall. Site care with betadine.

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Flippin a switch

• Whats the deal with the magnet?

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No Magnet
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With Magnet
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Rapid Atrial Pacing
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Rapid Atrial Pacing

• Used only in the atrium
• Pace at rates from 80-800
• Need to get higher than patients ATRIAL rate
• Physician must be present when in use
• Nurse may only connect
• Always have defibrillator available

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What are the possibilities?

• Single chamber pacemaker
• Dual chamber pacemaker
• Free standing RAP machine
• Think Frankenstein

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Rapid Atrial Pacing (single chamber)

• Flip open top of pacemaker
• Press enable to begin
• Set rate according to physician instruction or
  let MD set rate
• Rate will be higher than patients atrial rate
• Press hold to deliver until instructed to stop
• Will be done in bursts
• Pacing light will flash

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Rapid Atrial Pacing (dual chamber)

• Found on bottom half of pacer
• Must hit menu screen and scroll to menu 3
• Set rate by turning round knob
• Press select to deliver and HOLD until instructed
  to release

DDD
RAP 320
80 440 800
Press
SELECT
to
Deliver
Select
Rapid Atrial Pacing
3
Menu
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Permanent pacemakers
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Differences

• You cannot access pacing generator
• You cannot see leads
• Helps interpretation of strip if you know how
  pacemaker is set up
• Should have card
• Old records
• Request info from cardiologist

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You are in trouble!

• What can you try if you have a malfunction with a
  permanent pacemaker that is compromising your
  patient?

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Biventricular pacemakers?

• Pacing leads in the RV and into the coronary
  sinus
• Allow both ventricles to pace synchronously
• Improves heart function for patients with CHF
• EKG will not look different from single
  ventricular pacing

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The END