Craig hore on emergency pacing

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Asystole: a true story. Craig Hore

Transcript of Craig hore on emergency pacing

Page 1: Craig hore on emergency pacing

Asystole: a

true story.

Craig Hore

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And I don’t mean this one…

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Asystole is the end

60 year old man ?previously well Presented to regional hospital ED with

syncope Asystolic arrest soon after arrival Intubated CPR and adrenaline ~ 20 mins Called for senior advice (no ED SS)

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“Should we call it?”

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“Let me have a quick look…”

Patient is as described ECG rhythm strip:

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“Surely we can call it now?”

What would you do?

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Clinical examination

Patient looks surprisingly pink for at least 20 mins asystole

Confirm no peripheral pulses but palpable “pulses” with CPR

“Gut feeling” is hmmmm…….

What’s that rule about asystole?

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Is it really asystole?

Check other leads (I,III, V) – no obvious difference

Closer look at lead II – are those small bumps?

Rhythm strip with increased amplitude:

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“What now then?”

This calls for something completely different….

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Wasn’t thinking of this. But…?

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Transcutaneous pacing

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Transcutaneous pacing

“Older style” TCPM (Lifepak)

Rate set at 70bpm

Amplitude increased by 20 mA increments

Capture at 120 mA

Good pulses and SBP 130mmHg!

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Rembrandt van Rijn “The Raising of Lazarus” Los Angeles County Museum of Art, Los Angeles

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Rembrandt van Rijn “The Raising of Lazarus” Los Angeles County Museum of Art, Los Angeles

(WTF!)V

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The Raising of Lazarus…..

Patient started to move!.....

…opened eyes!!......

..responded to simple instructions!!!

Transcutaneous pacing did not appear to be causing him to much discomfort

What now?

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Temporary pacing wire Insertion of temporary transvenous pacing

wire in ED (RIJV; balloon flotation)

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Temporary transvenous pacing

How do I know it’s in the correct position?

Length of insertion

ECG electrode

Ectopics

CXR / bedside imaging

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Temporary transvenous pacing

What settings?

- demand?

- rate?

- sensitivity?

- output?

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Settings Capture threshold - the minimum electricity

output (mA) required to pace the heart (capture)

Asynchronous – paces at a fixed rate, ignoring any of the patient’s intrinsic activity

Demand - paces only if the intrinsic heart rate gets lower than the set rate. This is the usual setting.

Sensitivity – the sensitivity of the pacemaker to the patient’s intrinsic activity. When an intrinsic beat is “sensed’ (sensing light), this “inhibits” the pacemaker from firing

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Settings

Setting sensitivity – turn the output to 0 (prevent discharge); set rate below intrinsic rate; reduce sensitivity (increase amplitude) until no sensing of intrinsic activity (sensing threshold); set at ~ half the amplitude of this threshold.

Setting output – turn output to 0 and set rate at 10-15 bpm higher than intrinsic rate; increase output until capture occurs (capture threshold); set at 2-3 times higher than this threshold.

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Eventual outcome

Extubated inED Admitted to CICU History of syncope over several months –

neurological work-up was normal! Probable sick sinus syndrome Referred to Metropolitan hospital for

permanent pacemaker Full neurological recovery and return to usual

independent activities

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Summary

Don’t ignore those gut instincts

The old rule of thumb: a rhythm disturbance with haemodynamic compromise needs electricity

Temporary pacing can save lives

Transcutaneous pacing is getting better and easier

Temporary transvenous pacemaker insertion is getting better and easier

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GiottoThe Arena Chapel Frescoes: The Raising of Lazarus

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GiottoThe Arena Chapel Frescoes: The Raising of Lazarus

“It’s a miracle!! The Haematologist was right!”