CARDIOLOGY

Response5 letters. In order:
Chamber passed (A/V/D = Atria/Ventricular/Dual)
Chamber Sensed (A/V/D)
Response after sensing (Inhibited, triggered or Dual)
Programming – technical + complicateed
Arrhythmia control – Technical shit – read up if you want

DDD (most common for PPM)
= Dual (A+V) chamber pacing, Dual (A+V ) chamber sensing, Dual response to sensing in that it will triger or inhibit pacing depending on the underlying rhythm.

VVI (most common for Transvenous pacing. IE Pacing wire)
Ventricular paced, ventricular sensed
Inhibited – if ventricle senses contraction, it will not fire the pacemaker box.

ResponseInsert ECG p. 28
Retrograde P waves

ResponsePMT – re-entry tachycardia is created by the pacemaker forming an anterograde pathway and the AV node acting as a retrograde pathway. The retrograde p wave is sensed as native atrial activity and further ventricular pacing is propagated causing the inappropriate tachycardia

ResponseSensor may misfire from noise such as vibrations, loud noises, hyperventilation and surgical electrocautery.

ResponseDislodged PPM lead may be irritating the myocardium

ResponsePads on, cardiac monitoring on, Supplemental O2 SpO2>94%, Fluids MAP>70, analgesia Fentanyl 25mics.
Urgent cardiology referral and PPm interrogation
Apply magnet of the pacemaker which will inhibit the sensing and activate asynchronous ventricular pacing at the pre-set demand rate. This will block the anterior grade circuit and can terminate PMT
Vagal manoeuvre – may block AV conduction and terminate PMT
Adenosine/verapamil – Block AV conduction and terminate PMT
CXR ?pacemaker lead fracture or displacement
EUC ?Hypo/hyperkalaemia, hypomagnesaemia + correct any abnormality

ResponseWhen applied, converts asynchronous pacing which turns off the sensing mode of the pacemaker and allows the pacemaker to pace the atria and ventricles asynchronously

ResponseCXR – ensure lead position, exclude fracture or malposition
Potassium – Ensure no hyperkalaemia impairing cardiac function
pH – Acidosis can interfere with capture and pacing effectiveness
Troponin – Ischaemia can impair electrical function and interfere with pacemaker effect
PPM check - ? battery failing or increase resistance from lead fibrosis/scarring >> decreased output or failure to capture

ResponseRefractory Hypotension – SBP <90
Impaired mentation (new) – confusion or ALOC
Chest pain secondary to poor coronary perfusion
APO from L sided heart failure
Any end organ hypoperfusion

Questions all assume that there is some sort of bradyarrhythmia. I don’t thik you’d pace HR 80 sinus…

Overdrive Pacing in Tachyarrhythmia (EG VT Storm)

ResponseConsent/explanation
Analgesia/sedation (25 fent q5min, midaz 1mg Q5min)
Apply pads Anterior/posterior position
Connect ECG leads
Set pacemaker to demand
Turn pacing rate to 30 BPM above patients intrinsic rhythm
Set mA to 70
Start pacing and increase until pacing rate captured on monitor
If no capture at current of 120-130 mA >> resite electrodes and repeat above
Once pacing captured , set current 5-10 mA above threshold
Confirm mechanal capture by presence of pulse and signs of improved cardiac output.
Answer merged with LITFL

ResponseConfirm wires/cables connected
Optomise pad placement
Increase energy level to achieve electrical capture
If no improvement, contact cardiology for urgent transvenous pacing wire insertion