Demand pacing

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systemet

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Ok,

75 y.o. male, sitting in a living room chair in no apparent distress, GCS 15, strong regular radial p., pink, warm, dry. C/C intermittent mid thoracic back pain with bilateral arm radiation associated with dizziness, and "feeling like I'm going to pass out". Episodes occurring ~ 2/min, lasting 4-6 seconds. Patient st.s these have been ongoing x 1 hour, and that he has had previous episodes occasionally over the last 20 years, which he normally treats by having a chiropractor perform a realignment (!?). These have been medically investigated, but, per patient, no diagnosis given.

Hx is remarkable for CAD, HTN, dyslipidemia, COPD, MI x 1, triple vessel CABG x 15 years ago, and PCI with single stent placement last year. Physical exam reveals +2 peripheral edema, and ascites, which patient st.s is normal. At baseline patient has frequent dyspnea upon mild exertion, so probable chronic CHF. Pt. st.s he has been told that he has an irregular heart beat before (currently regular), but is not sure whether he has chronic a.fib.

ECG reveals a borderline sinus bradycardia alternating between 3rd degree AV block with a junctional pacemaker and Wenkebach. Episodes of diziness and back/arm pain are associated with "pauses", lasting 4-6 seconds, during which patient remains conscious, but becomes anxious and st.s that he feels like he's going to pass out. 12-lead shows no ST-T changes.

V/S are stable while perfusing in AVB, with HR 56/min, BP 168/90, RR 20, bG 6.0, T 36.5, RA SpO2 91%, w/ 4LPM, 99%.

I'm interested in what people's opinions are regarding pacing in this patient? I felt that he was tolerating the "pauses" quite well, but became concerned by the frequency, and the risk for VF. So I placed combo pads, got a line, and drew up some fentanyl, but was reluctant to demand pace while he was staying relatively stable throughout the episodes. As it was, these terminated about 5 minutes after I got IV access, and we had an uneventful transport. When I left the ER, the attending was discussing a pacemaker insertion with the patient.

I'm sitting back now, wondering if I was too relaxed with the situation, and should just have demand paced from the beginning of the call, then worried about IV access and analgesia later? The outcome of this call was good, but now I'm second-guessing whether I exposed my patient to more risk than was necessary by delaying the pacing than I would have by trying to pace while relatively stable. The patient's physiology seemed to be compensating for the events, but you always wonder how long this is going to last.

Any opinions?

Also, sorry that I don't have the ECGs. I didn't think to copy them.
 
I would not pace until the patient is hemodynamically unstable, which the patient was not. Most patients with transient heart blocks or complete heart blocks with junctional escapes tolerate and compensate fairly well. If their underlying escape rhythm was wide complex or ventricular I would be more aggressive.

If this patient walked into the ER they would be sent to our cardiac floor to be monitored and scheduled for a routine permanent pacemaker. If they started to decompensate then we would transcutaneous pace them or just place a transvenous pacer until their procedure.
 
systemet said:
ECG reveals a borderline sinus bradycardia alternating between 3rd degree AV block with a junctional pacemaker and Wenkebach. Episodes of diziness and back/arm pain are associated with "pauses", lasting 4-6 seconds, during which patient remains conscious, but becomes anxious and st.s that he feels like he's going to pass out. 12-lead shows no ST-T changes.

V/S are stable while perfusing in AVB, with HR 56/min, BP 168/90, RR 20, bG 6.0, T 36.5, RA SpO2 91%, w/ 4LPM, 99%.

I'm interested in what people's opinions are regarding pacing in this patient? I felt that he was tolerating the "pauses" quite well, but became concerned by the frequency, and the risk for VF. So I placed combo pads, got a line, and drew up some fentanyl, but was reluctant to demand pace while he was staying relatively stable throughout the episodes. As it was, these terminated about 5 minutes after I got IV access, and we had an uneventful transport. When I left the ER, the attending was discussing a pacemaker insertion with the patient.

I'm sitting back now, wondering if I was too relaxed with the situation, and should just have demand paced from the beginning of the call, then worried about IV access and analgesia later? The outcome of this call was good, but now I'm second-guessing whether I exposed my patient to more risk than was necessary by delaying the pacing than I would have by trying to pace while relatively stable. The patient's physiology seemed to be compensating for the events, but you always wonder how long this is going to last.

Any opinions?

Also, sorry that I don't have the ECGs. I didn't think to copy them.
Click to expand...

Chase said:
I would not pace until the patient is hemodynamically unstable, which the patient was not. Most patients with transient heart blocks or complete heart blocks with junctional escapes tolerate and compensate fairly well. If their underlying escape rhythm was wide complex or ventricular I would be more aggressive.

If this patient walked into the ER they would be sent to our cardiac floor to be monitored and scheduled for a routine permanent pacemaker. If they started to decompensate then we would transcutaneous pace them or just place a transvenous pacer until their procedure.
Click to expand...

Ditto what Chase says. Although a somewhat disturbing rhythm, your patient is hemodynamically stable.

And maybe it's splitting hairs - but a 3rd degree AV block with a junctional pacemaker and Wenkebach is not what I'd describe as a "sinus bradycardia".
 
jwk said:
And maybe it's splitting hairs - but a 3rd degree AV block with a junctional pacemaker and Wenkebach is not what I'd describe as a "sinus bradycardia".
Click to expand...

Feel free to split away :)

I've always referred to 2nd degree AVB as sinus bradycardia w/ 2nd degree AVB, as the ventricles are still being depolarised by a sinus event -- obviously not the case in 3rd degree AVB. I guess I was in error.

Thanks Chase and jwk for the input, greatly appreciated.
 
I can't see myself pacing this guy right away with what you've said. He is stable, for now at least. An IV and have my meds handy as well as the pacer pads and transport.
 
There's no way I'd pace this guy.
I agree with you putting the pads on him and starting an IV.
 
systemet said:
Ok,

75 y.o. male, sitting in a living room chair in no apparent distress, GCS 15, strong regular radial p., pink, warm, dry. C/C intermittent mid thoracic back pain with bilateral arm radiation associated with dizziness, and "feeling like I'm going to pass out". Episodes occurring ~ 2/min, lasting 4-6 seconds. Patient st.s these have been ongoing x 1 hour, and that he has had previous episodes occasionally over the last 20 years, which he normally treats by having a chiropractor perform a realignment (!?). These have been medically investigated, but, per patient, no diagnosis given.

Hx is remarkable for CAD, HTN, dyslipidemia, COPD, MI x 1, triple vessel CABG x 15 years ago, and PCI with single stent placement last year. Physical exam reveals +2 peripheral edema, and ascites, which patient st.s is normal. At baseline patient has frequent dyspnea upon mild exertion, so probable chronic CHF. Pt. st.s he has been told that he has an irregular heart beat before (currently regular), but is not sure whether he has chronic a.fib.

ECG reveals a borderline sinus bradycardia alternating between 3rd degree AV block with a junctional pacemaker and Wenkebach. Episodes of diziness and back/arm pain are associated with "pauses", lasting 4-6 seconds, during which patient remains conscious, but becomes anxious and st.s that he feels like he's going to pass out. 12-lead shows no ST-T changes.

V/S are stable while perfusing in AVB, with HR 56/min, BP 168/90, RR 20, bG 6.0, T 36.5, RA SpO2 91%, w/ 4LPM, 99%.

I'm interested in what people's opinions are regarding pacing in this patient? I felt that he was tolerating the "pauses" quite well, but became concerned by the frequency, and the risk for VF. So I placed combo pads, got a line, and drew up some fentanyl, but was reluctant to demand pace while he was staying relatively stable throughout the episodes. As it was, these terminated about 5 minutes after I got IV access, and we had an uneventful transport. When I left the ER, the attending was discussing a pacemaker insertion with the patient.

I'm sitting back now, wondering if I was too relaxed with the situation, and should just have demand paced from the beginning of the call, then worried about IV access and analgesia later? The outcome of this call was good, but now I'm second-guessing whether I exposed my patient to more risk than was necessary by delaying the pacing than I would have by trying to pace while relatively stable. The patient's physiology seemed to be compensating for the events, but you always wonder how long this is going to last.

Any opinions?

Also, sorry that I don't have the ECGs. I didn't think to copy them.
Click to expand...

Set it to demand at 50 if you're concerned, but the honest answer is if his pressure maintains through the episodes it probably isn't a big deal. You could also do 0.5mg atropine if it was a narrow escape as it may be a vagally mediated response in the AVN.
 
Like others have mentioned, I wouldn't have considered pacing this patient due to his hemodynamic stability. Despite the runs of 3rd degree block a HR of 56 is something I'm not much concerned with, although I would keep a close eye on the monitor during transport and run a couple more 12-leads before ER arrival. It may very well be an exacerbation of his past issues that are corrected with an 'alignment'.
 
jwk said:
And maybe it's splitting hairs ...
Click to expand...

At least you are not splitting Clare, it would be difficult to do things in two halves and might require some tape or something :D

I wouldn't pace this patient unless he became very significantly compromised
 
Chase said:
I would not pace until the patient is hemodynamically unstable, which the patient was not. Most patients with transient heart blocks or complete heart blocks with junctional escapes tolerate and compensate fairly well. If their underlying escape rhythm was wide complex or ventricular I would be more aggressive.

If this patient walked into the ER they would be sent to our cardiac floor to be monitored and scheduled for a routine permanent pacemaker. If they started to decompensate then we would transcutaneous pace them or just place a transvenous pacer until their procedure.
Click to expand...


With a junctional rhythm with wide QRS what kind of treatment would you do with a hemodynamically stable patient?
 
blachatch said:
With a junctional rhythm with wide QRS what kind of treatment would you do with a hemodynamically stable patient?
Click to expand...

???


Nothing
 
blachatch said:
With a junctional rhythm with wide QRS what kind of treatment would you do with a hemodynamically stable patient?
Click to expand...

Isn't a wide QRS indicative of a Ventricular rythm?:unsure:
 
Hunter said:
Isn't a wide QRS indicative of a Ventricular rythm?:unsure:
Click to expand...

Or a bundle branch block. Or you could have a compete heart block, allowing for both a supraventricular rhythm and ventricular rhythm.
 
Hunter said:
Isn't a wide QRS indicative of a Ventricular rythm?:unsure:
Click to expand...

Usually but not exclusively. Especially with various medications and electrolyte imbalances you can get some fairly wide complex rhythms that most likely are still originating from some region of the AV. It gets into kind of a grey area when you have a rhythm which originates in the lower nodal region or bundle of His. Clinically speaking it does not really matter and I would just assume Wide complex = Ventricular.

In my experience the majority of the patients I see in 3rd degree are in a junctional escape and tend to be fairly stable. It is not uncommon to get a direct admit from a physician's office for a patient who has been feeling sick for a few days/week and ends up being in a complete heart block. The few I have seen with ventricular escape were unstable and deteriorated quickly ending up with a transvenous pacemaker at the bedside (Really cool to see). All that is purely anecdotal

If the above patient was in a ventricular escape I would plan on pacing sooner then later.
 
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