Temporary Pacemakers

Deanna J. Tanner

Senior Clinical
Specialist
Medtronic CRDM
Central PA District
Medtronic, Inc., Minneapolis, MN
December 2007

Objectives
Temporary pacemaker indications
Identify different types of temporary
pacemakers
Basic temporary pacemaker concepts

Medtronic, Inc., Minneapolis, MN

December 2007

What Is a Pacemaker?
An artificial device that delivers a timed
electrical stimulus which results in
cardiac depolarization.
Keeps the heart from beating too slow.
Cannot restrict heart from going too
fast.
Medtronic, Inc., Minneapolis, MN
December 2007

Indications for Temporary Pacing

Heart block
Symptomatic Sinus bradycardia
Sinus arrest
Atrial and/or ventricular ectopic
arrhythmia suppression
During pacemaker generator
replacement of CHB pt with
slow/no
Inc., Minneapolis, MN
ventricularMedtronic,
escape
December 2007

Other Temporary Pacing Indications

Cardiovascular Surgery

Coverage for anesthesia and surgery in

patients with positive cardiac history
Treatment for CHB development during
surgery
Augment cardiac output post operatively
Medtronic, Inc., Minneapolis, MN
December 2007

NBG Codes
1st Letter
Chamber(s) Paced
A = atrium
V = ventricle
D = dual (both atrium
and ventricle)

2nd Letter

3rd Letter

Chamber(s) Sensed
A = atrium
V = ventricle
D = dual
O = none

Response to Sensing
I = inhibit
(Demand mode)
T = triggered
D = dual
O = none (Asynch)

Chamber paced
Chamber sensed
Action or response to a sensed
event

I
Medtronic, Inc., Minneapolis, MN
December 2007

Example of VVI pacing

.VL

Vt

II); "7'21""6"8

Ventricular
Spike
Medtronic, Inc., Minneapolis, MN
December 2007

DDD Pacing
Chamber Paced
Chamber Sensed
Action or Response
to a Sensed Event
D

D
Medtronic, Inc., Minneapolis, MN
December 2007

Example of

DDD pacing

Atrial Spike

Ventricular Spike

n
n
Medtronic, Inc., Minneapolis, MN

Asynchronous Modes
PACEMAKER WILL NOT SENSE WITH
MAGNET APPLICATION
AOO
.].

r,

I I

VOO

DOO
Medtronic, Inc., Minneapolis, MN
December 2007

VOO Asynchronous (Fixed)

Pacemaker will emit an output at a fixed
rate
regardless of intrinsic activity

Magnet application recommended only for patients that

or having a history of dependency or complete heart block.
Medtronic, Inc., Minneapolis, MN
December 2007

are pacing

Temporary Pacemaker
Procedure

Medtronic, Inc., Minneapolis, MN

December 2007

Temporary
Pacemaker
s

Temporary

Single

Dual
Medtronic, Inc., Minneapolis, MN
December 2007

Permanents

Insertion Sites
Internal Jugular Vein
External Jugular Vein

Subclavian Vein

Brachial Vein

Femoral Vein
Medtronic, Inc., Minneapolis, MN
December 2007

Lead Types
Endocardial/Transvenous lead
Transvenous lead is
introduced
into a vein and advanced into the
heart
Epicardial/Myocardial lead
An epicardial lead attached the
tooutside of the heart is introduced
through the chest wall
Medtronic, Inc., Minneapolis, MN
December 2007

Pacing Systems
One lead
implanted in the
right atrium
One lead
implanted in the
right ventricle
Or both
Medtronic, Inc., Minneapolis, MN
December 2007

Cable Connectors

Connector pins on
the lead(s) must be
fully inserted in the
patient connector
block

Observe polarity
Finger tighten only
Medtronic, Inc., Minneapolis, MN
December 2007

Cable to Device Connections

Cable clicks in place

Make sure device is OFF

Medtronic, Inc., Minneapolis, MN
December 2007

Emergency Connections

Temporary use only Leads do not lock in place

Medtronic, Inc., Minneapolis, MN

December 2007

Cable Connectors
New Federal
regulations made
cable changes
necessary

Medtronic, Inc., Minneapolis, MN

December 2007

Model 5388 Dual Chamber Temporary Pacemaker

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

Pace/Sense LEDs
Lock/Unlock Key
Lock Indicators
Rate Dial
Atrial Output Dial
Ventricular Output Dial
Menu Parameter Dial
Parameter Selection Key
Menu Selection Key
Pause Key
Power On Key
Power Off Key
Emergency/Asynchronous
Pacing Key
Lower Screen
Ventricular Output Graphics
Atrial Output Graphics
Upper Screen
Rate Graphics
Setup Indicators
DDI Indicator
Low Battery Indicator
Setup Labels
Medtronic, Inc., Minneapolis, MN
December 2007

Off / On Keys
Values at Power-On
Dual Chamber Pace/Sense
RATE
80 ppm
UPPER RATE
110 ppm

OFF

ON

Push once

Push twice
Medtronic, Inc., Minneapolis, MN
December 2007

Emergency Key
Emergency Pacing Values
RATE
A OUTPUT
V OUTPUT
PACING

Current Rate
MAX
MAX
ASYNC

NO SENSING!
Always available Single key
press enters Emergency mode

Use caution when setting the

device to asynchronous modes.

Medtronic, Inc., Minneapolis, MN

December 2007

Pause Key Check Patients

Intrinsic Rhythm

10 seconds ma

10 seconds max

Medtronic, Inc., Minneapolis, MN

December 2007

Rate and Output Adjustments

Single or Dual Chamber Pacing With Only 3 Dials!

Rate Dial

Max rate of
200bpm for
pediatrics

Atrial Output Dial

For Single Chamber pacing, turn
OFF Atrial output

Ventricular Output Dial

Medtronic, Inc., Minneapolis, MN

December 2007

Indicators
Pace/Sense Indicators
(Flashing Lights)

Low Battery
Light Indicator

Pace/Sense
Setup Indicators
(how is the device
setup?)
Medtronic, Inc., Minneapolis, MN
December 2007

Lock/Unlock Key

Padlock
Indicator
(is the
device
locked?)

5348 Temporary Pacer Controls

Medtronic, Inc., Minneapolis, MN

December 2007

Temporary Pacing
Parameters

Pacing rate
(heart rate)

Output/stimulation
threshold
Sensitivity
Medtronic, Inc., Minneapolis, MN
December 2007

Stimulation Threshold
The minimum electrical stimulus needed to
consistently capture the heart

Capture

Non-Capture

Medtronic, Inc., Minneapolis, MN

December 2007

Stimulation Threshold Procedure

1. Set RATE at least 10 ppm above patients intrinsic rate.
2. Decrease OUTPUT: Slowly turn OUTPUT dial counterclockwise
until ECG shows loss of capture.
3. Increase OUTPUT: Slowly turn OUTPUT dial clockwise
until ECG shows consistent capture.
This value is the stimulation threshold.
4. Set OUTPUT to a value 2 to 3 times greater than the stimulation
threshold value.
This provides at least a 2:1 safety margin.
5. Restore RATE to previous value.

Medtronic, Inc., Minneapolis, MN

December 2007

Capture vs Non-Capture
Capture

,I,

Non-Capture

"

"

,
' "I

II
II I
,

I1
1

I
,

,I
I"

I
I 1

I
II

I,

"

Medtronic, Inc., Minneapolis, MN

December 2007

,I

I " I
I

t" "
'

'I '

i I 'I

I
,
"

,I

II

-,

'I

Atrial/Ventricular Stimulation Thresholds

Capture

Loss of Ventricular
Capture

Medtronic, Inc., Minneapolis, MN

December 2007

What kind of capture?

Fusion/Pseudofusion/Confusion
Identify:
Capture Beats
Fusion Beats
Pseudofusion Beats
Medtronic, Inc., Minneapolis,
MN December 2007

Fusion/Pseudofusion/Confusion
Identify:
Capture Beats (A)
Fusion Beats (B)
Pseudofusion Beats (C)
Medtronic, Inc., Minneapolis, MN
December 2007

Fusion/Psuedofusion Beats

Intrinsic Beat
Intrinsic Beat

Fusion Beat

Paced Beat
Paced Beat

Pseudofusion Beat

FusiMoendtBroeniac,tInc.,

MPinsneeaupdolios,fuMsNion
December 2007

Beat

Sensing
Sensing is the ability of the pacemaker to
see when a natural (intrinsic) depolarization
is occurring
Pacemakers sense cardiac depolarization by
measuring changes in electrical potential of
myocardial cells between the anode and cathode
Expressed in Millivolts (mV)
Medtronic, Inc., Minneapolis, MN
December 2007

Sensing Threshold Procedure

1.

Set rate at least 10 ppm below patients intrinsic rate.

2.

Adjust output: Set OUTPUT to 0.1 mA (A OUTPUT for atrial threshold; V

OUTPUT for ventricular threshold).

3.

Highlight SENSITIVITY (atrial or ventricular) (Menu 1).

4.

Decrease SENSITIVITY: Slowly turn MENU PARAMETER dial

counterclockwise until pace indicator flashes continuously.

5.

Increase SENSITIVITY: Slowly turn MENU PARAMETER dial clockwise

until sense indicator flashes and pace indicator
stops flashing. This value is the sensing threshold.

6.

Set SENSITIVITY to half (or less) the threshold value.

This provides at least a 2:1 safety margin.

7.

Restore RATE and OUTPUT to previous values.

Medtronic, Inc., Minneapolis, MN
December 2007

Sensitivity - Objectives
Sensitivity (mV)
5 (mV)

To see or detect appropriate

intrinsic events
To filter out unwanted signals
(Similar to adjusting bedside
monitor settings)

2.5 (mV)

1.25 (mV)
Medtronic, Inc., Minneapolis, MN
December 2007

Sensitivity

The greater the number, the less sensitive the device to

intracardiac events

Amplitude (mV)

5.0

2.5

1.25

Time

Undersensing
Pacemaker does not see the
intrinsic beat, and therefore
does
respond
appropriately
UNDERSENSING
= OVERPACING

Medtronic, Inc., Minneapolis, MN

December 2007

not

VVI / 60

Oversensing
An electrical signal other than the
intended P or R wave is detected
OVERSENSING

= UNDERPACING

Medtronic, Inc., Minneapolis, MN

December 2007

Quick Step Up Temporary

Pacing
Turn on temporary pacemaker
Ensure battery is fresh
Engage cable/cables
Choose mode/rate
Define capture threshold apply safety
margin
Define sensing
apply safety
threshold margin
Lock

Medtronic, Inc., Minneapolis, MN

December 2007

Managing Temporary
Permanents in the OR
Setting

Medtronic, Inc., Minneapolis, MN

December 2007

Temporary Permanent Components

Pulse generator: power
source or battery
Lead

Leads or wires
IPG

Electrode
Electrodes

Body tissue
Medtronic, Inc., Minneapolis, MN
December 2007

Electrodes

Use of Magnets with Pacemakers

Locate patients pacemaker.
Place the round magnet
directly over the pacemaker.
Once the magnet is removed,
the pacemaker will revert to
normal function.

Pacemaker interrogation
is not routinely required
before or after surgery.
Medtronic, Inc., Minneapolis, MN
December 2007

Magnet Application and

Pacemakers
Magnet application causes
asynchronous pacing at a designated
magnet rate

Medtronic, Inc., Minneapolis, MN

December 2007

Temporary Pacemaker

Medtronic, Inc., Minneapolis, MN

December 2007

They tell me its the latest breakthrough

the nonsurgical pacemaker.

Medtronic, Inc., Minneapolis, MN

December 2007

Magnets and Devices

Identify device with patients ID Card. Call
company or page your local representative
with questions.
Medtronic
800.723.4636
Boston Scientific (Guidant)
800.227.3422
St. Jude (Ventritex)
800.733.3455