Pacemakers

CCN CLASS 2023

Learning Objectives
• Introduction and physiology
• Definition of pacemakers
• Types of pacemakers
• Clinical indications of pacemakers’
• Basic functioning of pacemakers
• Troubleshooting and programming
• Management of patients with pacemakers
• Risks and complications
Excitation and conduction in the heart

The sinoatrial node is the normal pacemaker of

the heart.
It’s the genesis of impulse through the heart.
In some abnormal conditions, other parts of the
heart can also exhibit intrinsic rhythmic
excitation.
The AV node fibers when not stimulated by some
extrinsic force, has an intrinsic rhythmic rate of 40
to 60 b/m.
Electrical conduction of the heart
Excitation and conduction in the
heart

The purkinje fibers intrinsically discharge at a rate

of about 15 to 40 times/ min.
Contrary the AV node normal rate is 70 to 80 times
/min.
How comes then, neither the AV node nor the
purkinje fibers controls the rhythm of the heart?
Excitation and conduction in the heart

The SA node discharge is considerably faster.

Thus, the new impulse from the SA node
discharges both the AV node and the purkinje
fibers before self excitation can occur in either of
the sites.
Ectopic pacemakers
Occasionally some other part of the heart
develops a rhythmic discharge that is more
rapid than that of the SA node.
This can also happen at either the AV node or
the purkinje fibers if there is an abnormality.
Under rare circumstances a place in the atria
or the ventricle develops excessive excitability
and becomes the pacemaker.
Ectopic pacemakers
• An ectopic pacemaker causes an abnormal
sequence of contraction at different parts of the
heart.
• This can cause significant debility in the pumping of
the heart.
 Pacemakers
Pacemakers are the electronic devices that can
be used to initiate the heartbeat when the
heart’s intrinsic electrical system cannot
effectively generate a rate adequate to support
cardiac output
The Pacemaker System

A simple electrical circuit consisting of:

 Pulse generator

 Pacing lead

 Healthy myocardium
Pulse Generator
Pacing pulse generator
 The pulse generator is designed to generate
an electrical current that travels through
pacing lead and exits through electrode that
is in direct contact with the heart. This
electrical current initiates a myocardial
depolarization.
 Pacing Lead System
Can be bipolar or unipolar

Bipolar Pacing System

In bipolar pacing system, two
electrodes (positive and negative) are
located within the heart
 Bipolar pacing system

 The negative
electrode is attached
to the negative
terminal, and the
positive electrode is
attached to the
positive terminal of
the pulse generator,
either directly or via a
bridging cable
 Unipolar Pacing System

 A unipolar pacing
system has only one
electrode (the
negative electrode)
making contact with
the heart.
Pacing Routes
 Transcutaneous
pacing

 Transthoracic
pacing

 Epicardial pacing

 Transvenous pacing
Transvenous pacing
 It involves threading an electrode catheter
through a vein into the right atrium or right
ventricle. Five different veins can be used.
 Antecubital approach
 Femoral approach
 Subclavian
 Internal jugular
 External jugular
• Transvenous pacemaker: Leads are threaded
transvenously to the chambers and attached to
the power source
• Epicardial pacing: The pacing leads are attached
to the epicardium during heart surgery
• Transcutaneous pacemaker: Noninvasive, power
source is attached to large electrodes placed
over the anterior and posterior chest
Types of Pacemaker
Permanent and temporary
pacemakers
Permanent pacemaker
It is implanted totally with in the body.
The power source is implanted subcutaneously
usually over the pectoral muscle on the patients
non dominant side.
The pacing leads are threaded transvenously to
the chamber to be paced
Permanent Pacemakers
Indications
• Acquired AV block
• Second- and third-degree block
• Cardiomyopathy
• BBB
• SA Node dysfunction
• Tachydysrhythmias
Temporary
pacemaker
• It has the power source
outside the body
• Transvenous,Epicardial
pacing and Transcutaneous
pacemakers
Classification based the heart chamber
being paced
• Single chamber pacing: right atrium or the right
ventricle is paced. Only one pacing lead is used.
• Dual chamber pacing, both the right atrium and
right ventricle are paced. Requires two pacing leads.
• One lead is placed in the right atrium, and the other
lead is placed in the right ventricle.
• Note that the designation “MR conditional” means
that the implanted pacemaker pose no known
hazards in a specified MRI environment
Classification according to type of
pacing
• Atrial pacing, ventricular pacing, and AV pacing.
• Atrial pacing: SA node failure. – Symptomatic
sinus bradycardia or sinus arrest.
• Ventricular pacing - complete av block
• AV pacing - SA node failure and a complete AV
block.
Classification according to
pacemaker modes
Asynchronous vs synchronous.
• Asynchronous mode/fixed rate
A pacemaker set to to asynchronous mode will fire at a
consistent, constant rate regardless of the heart’s
electrical activity.
• Synchronous mode/demand type
A pacemaker set to synchronous mode will fire only
when the heart’s intrinsic rate falls below a preset
number. Another name for this is a demand pacemaker.
Classification according to Pacemaker
nomenclature
• Pacemaker nomenclature is most often written as a series of three
letters (i.e., VVI) but can be as much as five (DDDRO
• In order, the 3 or 5 letter nomenclature stands for:
1. Chamber Paced: A (atrium), V (ventricle), D (dual)
2. Chamber Sensed: A (atrium), V (ventricle), D (dual)
3. Response to Sensed Beat: I (inhibit), T (trigger), D (dual), O (none)
4. Rate Responsiveness: R (rate responsive), O (none)
• Automatically increases the pacing (and cardiac output) to meet
an increase in exertion
5. Multisite Pacing: O (none), A (atrium), V (ventricle), D (dual)
n.b. only the first three characters matter.
 Indications
 Bradycardia
Sinus bradycardia and arrest
Sick sinus syndrome
Heart blocks
 Tachydysrhythmias
Supraventricular
Ventricular
 Permanent pacemaker failure
 Support cardiac output after cardiac surgery
 Diagnostic studies
• Electrophysiological studies
• Atrial electrogram
Pacemaker Settings
1. RATE

2. OUTPUT

3. SENSITIVITY
 RATE
 It regulates the number of impulse
that can be delivered to the heart per
minute.
 The rate setting depend on the
physiological needs of the patient,
but it is generally maintained
between 60-80 beats/ min.
 If the pacemaker is operating in dual-
chamber mode, the ventricular
control rate also regulate the atrial
rate.
 OUTPUT
 It is the amount of electrical current
(measured in milliamperes [mA]) that is
delivered to the heart to initiate
depolarization.
 The point at which depolarization occurs
is termed threshold and is indicated by a
myocardial response to the pacing
stimulus (capture)
 SENSITIVITY

 The sensitivity control regulates the ability

of the pacemaker to the heart’s
intrinsic electrical activity.
 Sensitivity is measured in millivolts (mV)
and determines the size of the intracardiac
signal that generator will recognize
 PACING ARTIFACTS
 All patients with temporary pacemaker
require continuous ECG monitoring.
 The pacing artifact is the spike that is seen on
the ECG tracing as the pacing stimulus is
delivered to the heart.
 A P wave is visible after the pacing artifact if
atrium is being paced.
Pacing Artifacts
Pacing Artifact
 -

Troubleshooti
ng
 Failure to Fire
 Failure of the pacemaker deliver the pacing
stimulus results in the disappearance of the
pacing artifact, even though the patient’s
intrinsic rate is less than the set rate on the
pacer.
 This can occur either intermittently or
continuously and can be attributed to failure of
the pulse generator or its battery
 Failure to fire
•CAUSES

• Loose head hookups

• Dead battery

• Malfunctioning pulse generator

 Failure to fire
•INTERVENTIONS

• Secure lead hookups

• Replace battery

• Replace pulse generator

 Failure to Capture
 Ifthe pacing stimulus fires but fails to initiate a myocardial
depolarization, a pacing artifact will be present but will not
be followed by the expected P wave or QRS complex,
depending on the chamber being paced.
 Failure to Capture
•CAUSES

• Pacemaker output too low

• Catheter dislodged

• Loose connections
 Failure to Capture
•INTEREVENTIONS

• Increase pacemaker output

• Reposition catheter

• Secure all connections

 Failure to Sense
• UNDERSENSING
• In it pacemaker fires at wrong times or for the wrong
reasons (help being given when none is needed)
• OVERSENSING

• In it pacemaker fires incorrectly senses depolarization

and refuses to fire when it should (won’t pace when the
patient actually needs it)
Failure to Sense
 Failure to sense
•CAUSES
• Electrolyte imbalance
• Disconnection or dislodgement of lead
• Edema or fibrosis at the tip of electrode
• Drug interaction
• Drug battery
 Failure to sense
•INTERVENTION
• Correct the sensitivity setting

• Replace battery

• Secure all connections

• Correct the underlying cause

 Medical Management
• The physician determines the pacing route based on the
patient’s clinical situation.
• Generally transcutaneous pacing is used in emergent
situations until a transvenous lead can be secured.
 Medical Management
• If the patient is undergoing heart surgery, epicardial leads
may be electively placed at the end of the operation. The
physician places the transvenous or epicardial pacing
lead(s), repositioning as needed to obtain adequate
pacing and sensing thresholds.
 Nursing Management
Four primary areas:
 Assessment and prevention of pacemaker
malfunction,
 Protection against micro shock,
 Surveillance for complications such as
infection
 Patient education.
Prevention of Pacemaker
Malfunction
 Continuous ECG monitoring is essential to facilitate
prompt recognition and appropriate intervention for
pacemaker malfunction.
 The temporary pacing lead and bridging cable must be
properly secured to the body with tape to prevent the
accidental displacement of the electrode, which can
result in failure to pace or sense.
 The external pulse generator can be secured to the
patient’s waist with a strap
Prevention of Pacemaker
Malfunction
 For the patient on a regimen of bed rest, the pulse
generator can be suspended with twill tape from an
intravenous (IV) pole mounted overhead on the ceiling.
 This not only will prevent tension on the lead while the
patient is moved (given adequate length of bridging
cable) but will also alleviate the possibility of accidental
dropping of the pulse generator.
Prevention of Pacemaker
Malfunction
The nurse
 inspects for:
 loose connections between the lead(s) and pulse
generator on a regular basis.
 Replacement batteries and pulse generator must
always be available on the unit.
 Pulse generators (new generation) provide a
low-battery signal 24 hours before complete loss
of battery function to prevent inadvertent
interruptions in pacing. The pulse generator
must always be labeled with the date that the
battery was replaced.
Micro-shock Protection
• It is important to be aware of all sources of EMI
(ElectroMagnetic Interference)within the critical
care environment that could interfere with the
pacemaker’s function.
• Sources of EMI in the clinical area include
electrocautery, defibrillation current, radiation
therapy, magnetic resonance imaging devices,
and transcutaneous electrical nerve stimulation
(TENS) units.
 Micro-shock Protection
 In most cases, if EMI is suspected of precipitating pacemaker
malfunction, converting to asynchronous mode (fixed rate)
will maintain pacing until the cause of the EMI is removed.
 The pacing electrode provides a direct, low resistance path to
the heart, the nurse takes special care while handling the
external components of the pacing system to avoid
conducting stray electrical current from other equipment.
 Infection
• Infection at the lead site is a rare but
serious complication associated with
temporary pacemakers
• The (sites) is carefully inspected for
purulent drainage, erythema, and edema,
and the patient is observed for the signs of
systemic infection.
 Infection
 Site care is performed according to
institution’s protocol. Although most
infections remain localized, endocarditis can
occur in patients with endocardial pacing
leads.

A less common complication associated
with transvenous pacing is myocardial
perforation, which can result in rhythmic
hiccoughs or cardiac tamponade.
Nursing care

• Continuous ECG monitoring of heart rate & Rhythm.

• Monitor vital signs for every 15 minutes.
• Monitor urine output.
• Observe for the presence of dysarrhythmia.
• Avoid injury .
• Post insertion chest x-ray.
• Monitor signs &symptoms of haemothorax &
pneumothorax.
Nursing care
• Evaluate continuously for evidence of bleeding.
• Monitor for evidence of lead migration.
• Auscultate for pericardial friction rub.
• Provide an electrically safe environment.
• Prevent infection.
• Relieve anxiety.
POST- OPERATIVELY

Nursing care for a patient in a sling

• Usually, a patient’s arm is put in a sling
• The patient should be instructed to minimize all shoulder
movement.
• avoid lifting their arm above the shoulder so they don’t displace
the leads that were just placed during surgery.
• check the insertion site for bleeding and for any signs of infection.
Assess for hiccups
• consistent hiccups are an indication that the pacemaker is pacing
the patient’s diaphragm and not their heart - surgical intervention
may be required.
patient teaching for a patient with a pacemaker

• Check pulse daily.

• Avoid weight lifting.[>20 lb]
• Avoid shower.
• Avoid lifting hand over shoulder level.
• Wear loose-fitting clothing.
• Avoid trauma to the area.
Patient teaching
• Come for regular check up.
• Avoid close exposure to magnetic force,
radiation, metal detector etc
• Carry all time pacemaker identity card
• All electronic equipments should be grounded
and repaire
ADVERSE EFFECTS
1. Pacemaker syndrome
2. Infection
3. Venous thrombosis
4. Air embolism and Hematoma
5. Lead dislodgement and Perforation via
pacemaker lead (Liver, Stomach, Diaphragm)
6. Pneumothorax
7. Muscle stimulation
8. Ectopic beats like PVC’s