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 Definition.
 Indications for invasive cardiac pacing.

 Types of pacemakers.

 Components of Pacing.

 Pacemaker concepts:

1) Connection
2) Output (rate, amount, chamber)
3) Capture
4) Sensetivity
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 Is an artificial electronic device that provide
electrical stimuli to cause cardiac contraction during
periods when intrinsic cardiac electrical activity is
inappropriately slow or absent.
 Used to initiate myocardial contractions when

1) Intrinsic stimulation is insufficient,

2) The native impulses are not being conducted,
3) The heart rate is too slow to maintain an adequate
cardiac output.

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 Care of Patients With Pacemakers
 Complications Related to Pacemakers.
 Patient education regarding permanent
pacemaker insertion procedure.

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 Symptomatic sinus arrest.
 Suppression of ventricular ectopy resulting from bradycardia
 Atrial fibrillation
 Bradycardia/tachycardia syndrome
 Symptomatic sinus bradycardia
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 Œype I (occasionally) and type II second-
second-degree
atrioventricular block
 Acute bifascicular or trifascicular block
 Complete atrioventricular block
 Cardiac arrest with ventricular asystole
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 ¦verdrive ventricular pacing to suppress or prevent
ventricular ectopic activity
 ¦verdrive atrial pacing to ´breakµ supraventricular
tachycardia or atrial flutter
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 urophylactic use during anesthesia and surgery in
patients with a history of acute coronary syndrome or
cardiac dysrhythmias
 Œreatment for complete heart block developed during
or after surgery
 Cardiac output augmentation postoperatively
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 Œreatment with Ƣ-blocking agents

 Srious bradydysrhythmias often occur even without

drug therapy.
 Œemporary pacing after myocardial infarction can be a
lifesaving intervention, allowing patients to enjoy the
benefits of Ƣ-blocker therapy while simultaneously
maintaining an adequate heart rate and cardiac output.

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 Œ





 Permanent/ long-
long-term pacemaker:
 An incision (cut) is made in the neck or chest. The
leads are guided through a vein into the heart, and
attached to the generator.
 The generator is placed in a pocket under the skin.

 Transvenous/ Temporary pacemaker :

 The leads for the pacemaker are guided into the

heart through an incision in neck, chest, or leg.
 The generator is worn outside the body in a small
pouch. Ú
 

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|) Œhe 




 that initiates electrical

stimulation.
 Œhree basic 






are available:

 


  

, are adequate for enhancing
heart rate in patients with an intact cardiac conduction system.
2. Single-chamber 
   pacers, designed for patients
with normal contractility who require an increase in heart rate.
3.  
   


 

, pace both atrial and
ventricular chambers.
urovide synchronization between the atria and the ventricles
for optimal cardiac output. R
 uermanent pacemaker pulse generators are
usually powered by 





   










 
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.
 3eplacing the generator usually requires a simple
procedure in which a repeat incision is made, the
old generator is removed, and a new generator is
implanted and joined with the existing leads.

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2) Œhe pacing generator is connected to  




and may or may not require a

 
.
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  ailure to pace may be due to a malfunction or
disruption of mechanical components.
 May also be due to poor myocardial function
associated with electrolyte disturbances, myocardial
scarring, or any factors that affect impulse conduction
or cardiac contractility.

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(Connection, output, capture, sensetivity)

|) Œhe 
 between the pacemaker generator

and the heart:
A) Unipolar electrode wire, only the negative electrode is
in direct contact with the heart.
B) Bipolar electrode wires, both negative and positive
electrodes lie within the heart.
 uacemakers can be either unipolar or bipolar.

 Distinguishing between the negative and positive

electrodes is important so that the wires are connected
appropriately to the pulse generator. |
 

 Œypes of invasive temporary pacing:

|) Œhe Œ 


category, involves a pulse

generator externally connected to 2 electrode wires,
threaded through a large vein into either the right
atrium or the right ventricle. Œhese wires directly
contact the endocardium within the heart.

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 Initiated after cardiac surgery. Electrodes are lightly sutured to
the epicardium before the thorax is closed.
 Œhese pacing wires are pulled through the skin and secured to
the external chest wall, ready for attachment to a temporary
pacing generator as needed.
 A patient may have a single set or a double set of electrodes,
but each set of electrodes includes 2 wires that protrude from
a stab incision in the chest wall.
 Ventricular pacing wires exit through the left side of the
sternum; atrial pairs are placed on the right side.
 Having identifying labels on the wires is helpful. If no labels
are present, ascertaining which wire is which (and marking the
wires accordingly) can save precious time later in emergency
situations.
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Œemporary pulse
generator for a
dual-chamber
pacemaker
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 Œhe sole function of the generator is to supply sufficient
energy to the heart muscle to stimulate a contraction.
Œ


 determines the number of stimulations to be
delivered per minute.
 Œhe original rate setting depends on both the patient·s
condition and the reason for pacing.
 3ates for a surgical patient can start as high as 90 to ||0
beats/min.
 In medical patients, therapy is generally started at 70 to 90
beats/min.
 In patients who have had cardiac arrest, the initial rate is 80
beats/min.
 Œhe heart rate on a patient·s rhythm strip should never be
lower than the patient·s set pacemaker rate. |w
[Œ

¦  
 Is the level of energy delivered by the pulse generator to the
heart to initiate depolarization.
 ¦utput is measured in milliamperes (mA).

 Œhe usual starting point is |0 mA in nonurgent situations.

 ¦utput is then slowly increased until capture is obtained and

the ´pacing thresholdµ is defined.
 Œhis level is not constant; it fluctuates over time as an
endothelial sheath forms around the tips of the electrodes.
Œherefore, to prevent loss of capture, the output is set |.5 to 3
times higher than the identified pacing threshold.
 In emergent circumstances, starting with a high output (|5-20
mA) is recommended.
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Œ




 Œhe location in the heart to which the energy is
delivered.
 Œhe atrial, ventricular, or both chambers can be paced.

 uulse generators for dual-chamber pacemakers have

separate atrial and ventricular output controls.
 Œhe settings for the 2 chambers may be different or
identical.

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 £&
  

 Œhe ability of the electrical impulse to initiate a cardiac
response, is detected by examining an electrocardiogram.
response
 Capture is both an electrical & a mechanical event.
 Electrical capture is indicated by a pacer spike followed by a
corresponding u wave or Q3S complex, depending on which
chamber is being paced ( ).
 If the atrium is paced, the spike appears before the u wave.
 If the ventricle is paced, the spike occurs before the Q3S
complex.
 Because the pacemaker causes the heart to depolarize in an
artificial fashion, the path of depolarization is abnormal,
resulting in widened u waves and Q3S complexes.
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Jormal electrical capture, atrial pacer. Jormal atrial electrical
capture is demonstrated by a pacer spike (Ap) followed by a
corresponding u wave.
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Abbreviations: Ap, atrial pacing; As, atrial stimulation (intrinsic).
Jormal electrical capture, ventricular pacer. Jormal ventricular
electrical capture is demonstrated by a pacer spike (Vp) followed
by a corresponding, widened Q3S complex.
Abbreviations: Vp, ventricular pacing; Vs, ventricular stimulation (intrinsic). 
 A pacer spike without a corresponding u wave or
Q3S complex indicates failure to capture ( ).
 If loss of capture occurs, the patient is assessed first
and then connections and settings are checked to
detect disconnections, broken wires, or other
mechanical issues.
 If the patient·s condition is stable, threshold testing is
done.
 If hemodynamic compromise exists, the
milliamperae/amount is quickly increased until
capture occurs.

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 Œurning the patient onto his/her left side may also
improve capture by increasing contact between the
electrode and myocardial tissue.
 Electrical capture alone is inadequate. Adequacy of
mechanical capture is assessed by feeling for a pulse or
checking blood pressure.
 Mechanical capture exists when the pacer spike and
its corresponding Q3S complex are followed by a
cardiac contraction.

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 ailure to capture, dual-chamber pacemaker.  ailure to capture
occurs when a pacer spike is present but is not followed by a
corresponding waveform (u wave or Q3S complex). Arrow
indicates electrical stimulus without ventricular capture. -
 º


 Œhe ability of the generator to detect & recognize the
impulses the myocardial tissue is generating on its own
(Intrinsic cardiac activity ).
 Intrinsic activity stimulates better contractions, &
more effective forward blood flow, from the
chambers of the heart, especially when the atria and
ventricles are intrinsically beating synchronously.
 30% of normal C.¦. is due to the atrial ´kickµ or atrial
systole, that occurs during ventricular filling when the
2 chambers perform in sync.
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 hen atrial beats are unsynchronized or absent, as in
atrial fibrillation, atrioventricular block, or sinus arrest,
cardiac output decreases because less blood than usual
is ejected from the atria during ventricular diastole.
 Intrinsic beats must be supplemented when the rate is
insufficient or conduction of the beats does not
generate ventricular contractions.
  or maximum effectiveness, paced beats and intrinsic
beats must be synchronized.
 Œo synchronize the beats, the generator first analyzes
the intrinsic rhythm and then stimulates the heart only
as needed.
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 Adjusting the sensing level sets the pacer to ´lookµ for
intrinsic beats, & provide pacing on demand.
 uacemaker generators can be programmed to deliver
an impulse to the ventricle each time an atrial beat is
sensed, or they can be set to stimulate only when no
intrinsic beat has been detected during a
predetermined interval.
 Œhe sensitivity setting is measured in millivolts (mV)
and is initially set at about 2 to 5 mV.
  ailure to sense occurs when the generator does not
recognize the heart·s intrinsic impulses.

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  ailure to sense, single-chamber atrial pacemaker.  ailure to
sense occurs when the generator does not detect intrinsic
beats and initiates an inappropriate impulse that may or may
not capture. Arrow indicates an atrial beat not sensed by the
pulse generator, which is followed by a pacer spike. R
 actors that influence capture and sensing

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 Œhe most common cause of failure to sense is
displacement of the electrode.
 3epositioning the patient on his or her left side may
improve contact between the electrode and the
myocardium.
 If the response is still inadequate, then the sensitivity
must be increased by turning down the millivoltage,
allowing the generator to detect beats that occur at
lower millivolt levels.
 If the pacemaker is detecting beats that are not
actually occurring (inappropriate sensing), then the
sensitivity threshold must be increased to block out
artifact by turning up the millivoltage. £|
 Care of uatients ith uacemakers
|) Electrical safety practices, to prevent microshocks
which are associated with ventricular dysrhythmias.
 Always wear gloves when handling electrodes

 Cover unused transthoracic wires

2) Œhe pulse generator must be placed in a location

where it will not be dropped on the floor.
3) Lengthy cables attached to the pacemaker need
careful attention so that wires are not inadvertently
dislodged.

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º) 3outine nursing care of regular cardiovascular assessment to
evaluate pulses, level of consciousness, heart rhythm, pacer
activity, and hemodynamic response.
5) Œhe wires must be secure and not at risk for dislodgement.
 check to see if the wires are intact and note the number &
location.
6) Care for a transvenous wire site:
 Daily assessment of the insertion site.

 dressing are changed as prescribed

 cleaned with povidone-iodine/another antimicrobial agent

 A sterile occlusive dressing is applied, with changes every º8

to 72 hours.

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7) After cardiac surgery & once dressings are removed,
care of the epicardial site should be performed daily
whether the site is left open to air or covered with a
light dressing.
 Œhe area is cleaned with isotonic sodium chloride
solution and assessed for redness or drainage.
 Œhe wires must be taped securely to the skin to
prevent accidental dislodgement.

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8) Capture and sensitivity threshold testing should be
performed every |2 to 2º hours to determine the best
settings for the generator.
 As time passes, both transvenous and epicardial wires
acquire endothelial sheaths around their tips and thus
require more milliamperes to capture and fewer
millivolts to sense.
 Œhreshold testing is generally contraindicated when
patients are being paced more than 90% of the time
because of the risk of losing capture while the patients
are dependent on generator-initiated beats.

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 Complication treatment depends on the
etiology
 Pneumothorax, being dependent on size, may
Pneumothorax,
require chest thoracostomy.
thoracostomy.
 Erosion of the pacer through the skin
skin,, while rare,
requires pacer replacement and systemic antibiotics.
antibiotics.
 Hematomas may require drainage
drainage..
 Lead dislodgment usually occurs within 2 days
following implantation of a permanent pacer and
may be seen on chest radiography.
radiography. If the lead is
floating freely in the ventricle, malignant
arrhythmias may develop.
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 Thrombosis is rare and usually presents as
unilateral arm edema.
edema. Treatment includes arm
elevation and anticoagulation.
 Advanced life support protocols,
protocols, including
defibrillation,, may safely be executed in
defibrillation
patients with pacemakers in place. Sternal
paddles are placed at a safe distance (10
(10 cm)
generator.
from the pulse generator.

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 Patient education regarding
permanent pacemaker insertion
procedure

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 [efore the Procedure
 Xou will be asked to sign a consent form.
 If you are pregnant or suspect that you are pregnant
pregnant,,
you should notify your physician.
 Notify your physician if you have a history of
bleeding disorders or if you are taking any
anticoagulant (blood-
(blood-thinning) medications.
medications. It may
be necessary for you to stop some of these
medications prior to the procedure.
 Xour physician may request a blood test prior to the
procedure.
 Remove any jewelry or other objects that may
interfere with the procedure.
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 Not eat or drink after midnight the night before
the procedure.
 Tell your doctor and nurses if you are allergic
to any medicines or Iodine.
 Empty your bladder before the procedure.
 Xour chest area may be shaved,
shaved, and will be
prepared for the procedure.
 Xou may be given medicine to help you relax.
 An intravenous line (IV line) will be inserted
into your arm.

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 During the urocedure
 Xou will be placed on a thin, hard table.
table.
 A large drape will be placed on the chest area where
the pacemaker will be inserted.
 Xou will be given an antibiotic in your IV.
 The doctor will insert the pacing leads (wires) into
the heart, and then attach the leads to the pacemaker
or generator.
 Xou may be awake during the procedure, and you
may be asked to take deep breaths.
º
 There will be a large camera that rotates and
takes pictures of your heart as the leads are
being positioned by the doctor.
 It is very important to tell the doctor or nurse if
you have any discomfort or chest pain.
 A large bandage that applies pressure will have
been placed on the incision site (the area where
your stitches are).

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ºº
 After the urocedure:
 Jot raise the arm on the same side as the incision
site above your shoulder for three weeks.
Arrange to have someone drive you home from the
hospital following the procedure.

º-
 Jotify your physician &/or nurse to report any
of the following:
ü  ever and/or chills

ü uain, redness, swelling, or bleeding or other

drainage from the insertion site.
ü Chest pain/pressure, nausea and/or vomiting,
profuse sweating, dizziness and/or fainting.
ü Swelling at the pacemaker site.

ü Shortness of breath

ü ualpitations (a feeling of irregular heartbeat).

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 ©


 Not do any lifting or pulling on anything for a

few weeks.

 Keep the insertion site clean and dry.

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 Always carry an ID card that states you are wearing
a pacemaker.
 Tell your surgeon or dentist that you have a
pacemaker; so that electrocautery will not be used to
control bleeding (the electrocautery device can
change the pacemaker settings).
 Always consult your physician if you have any
questions concerning the use of certain equipment
near your pacemaker.
 Always consult your physician when you feel ill
activity, or when you have questions about
after an activity,
beginning a new activity.
activity. ºÚ
 A follow-up visit at the physician¶s office is
usually scheduled÷every six to 12 months, to
ensure that the pacemaker is working properly
by÷programming testing and If needed battery
replacement is necessary ÷

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 uermanent uacemaker programming

 Can be performed noninvasively by an

electrophysiologist or cardiologist.
 uatients should carry a card with them providing
information about their particular model. Œhis
information is crucial when communicating with the
cardiologist about a pacer problem.
 Most pacemaker generators have an x-ray code that
can be seen on a standard chest x-
x-ray.

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 Household appliances ² microwave energy.
 Cellular phones²
phones² Avoid placing a cell phone over the
pacemaker (especially the antenna of the phone), and should
not carry it in a pocket close to or over the pacemaker while
the phone is on.
 Electromagnetic Security Systems ² found in or near the
workplace, at airports, in shopping malls, at courthouses, or
in other high
high--security areas.
ü [e aware of the location of security systems and move
through them at a normal pace.
ü Avoid sitting or standing close to a security system. -£
 External electrical equipment ² In places that
contain welding equipment or motor-
motor-generator
systems.
ü Remain at least two feet from external
electrical equipment,
ü Verify that the equipment is properly
grounded,,
grounded
ü Wear insulated gloves when using electrical
devices,
ü Leave the work area immediately if they
experience lightheadedness or other
concerning symptoms.
-º
 Diagnostic or therapeutic procedures:
Certain diagnostic or treatment procedures may
interfere with pacemakers. Thus, clinician
recommend avoiding these procedures or using
special precautions, such as reprogramming of the
pacemaker. Such procedures include:

üMagnetic resonance imaging (MRI), a noninvasive

diagnostic imaging procedure that uses a strong
magnetic field that is pulsed on and off at a rapid rate.

--
ü Transcutaneous electrical nerve/muscle stimulators,
stimulators,
a method of pain control involving the application of
electrical impulses to muscle or nerve via electrodes
placed on the skin
ü Diathermy
Diathermy,, the production of heat in body tissues for
therapeutic purposes through high-
high-frequency
electromagnetic radiation or microwaves
ü Extracorporeal shock wave lithotripsy,
lithotripsy, the use of
sound waves to break up stones (calculi) in the
urinary tract or gallbladder
ü Therapeutic radiation for cancer or tumors,
tumors, which
can cause permanent pacemaker damage from the
radiation
-]
Œhe End

Œhank You

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