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Home | Articles | Cardiac | Pacemakers

Pacemakers

Last updated 21st June 2022

Introduction

  1. Patients with bradycardias due to conducting system disease may require a pacemaker which can be either temporary or permanent and inserted as an emergency or electively.
  2. We have a very limited capacity to insert pacemakers as an emergency in Dumfries at present.
  3. See below for advice on management of the common emergency pacing scenarios

Temporary Pacing

  1. Patients requiring a temporary pacemaker will generally be transferred to QEUH in Glasgow for this procedure – attachment below describes how to refer.
  2. If the patient is unstable on Isoprenaline or requires transcutaneous pacing in Dumfries, insertion of a temporary pacing wire should be considered. This will be done in Critical Care by the consultant cardiologist on call, who will be responsible for manipulation of the temporary wire.
  3. Pacing electrode inserted through central vein eg internal jugular , subclavian or femoral vein.
  4. Output usually set at >2x threshold value to prevent loss of capture – check threshold at least twice daily.
  5. Transcutaneous pacing is uncomfortable for patient but can usually be tolerated if necessary until temporary line inserted

Indications for Temporary pacing

  1. Stable, not Haemodynamically Compromised, Patient with Complete Heart Block
    Monitor continuously either in Critical care or D8 on telemetry
    Refer to Cardiology for elective list (Tuesday & Friday)
  2. Complete Heart block, Requiring Isoprenaline Infusion, but Stable
    Monitor continuously in Critical Care.
    Refer for urgent transfer to Queen Elizabeth Hospital, Glasgow or University Hospital Hairmyres (as per pacing rota held by switchboard).
  3. Complete Heart Block, Unstable, not fit for Transfer Without a Temporary Pacing Lead
    Monitor continuously in either ED or Critical Care
    On call ED consultant &/or on call anaesthetic consultant to place temporary pacing wire
    Refer for urgent immediate transfer to either Queen Elizabeth University Hospital, Glasgow or University Hospital Hairmyres (as per pacing rota held by switchboard).

Permanent Pacing

  1. Refer to cardiology for elective list on Tuesdays and Fridays
  2. Click here for Cardiac Device Request Form [pdf], BHF Living with a Pacemaker and BHF Pacemaker, Your Quick Guide
  3. Single chamber devices such as VVI means paces ventricle, senses ventricle and is inhibited by ventricular contraction
  4. Dual chamber devices maintain AV synchrony – DDD means paces both chambers, senses both chambers and reacts in two ways – pacing inhibited by spontaneous activity and ventricular pacing triggered by spontaneous atrial activity
  5. Rx Teicoplanin 400mg IV one off stat dose as antibiotic prophylaxis just prior to implantation.

Antibiotic Cover for Permanent pacemakers

  1. A stat dose of Teicoplanin within 30-60 minutes prior to pacemaker implantation.
  2. If patient <40kg give 400mg; if patient >40kg give 800mg by slow IV injection over 3-5 minutes
  3. No oral/further doses post insertion (unless specified by the Cardiologist).
  4. If allergic contact Microbiology for advice.

Recognising Paced Rhythm

  1. The clue to paced rhythm is the pacing spike which immediately precedes the P wave or QRS complex or both.  The trace immediately below shows the ventricular pacing spike of a VVI pacemaker.
  2. If there are two spikes then patient has a dual chamber device. Note all QRSs are paced in example shown below but that some P waves have been sensed (right hand side of trace).

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Content updated by Prof Chris Isles