Transvenous Pacemaker; made simple

Case study: You are responding to a code blue. Patient went bradycardic in the 30’s; unresponsive. Atropine 1 mg was given but did not improve heart rate. Previous EKG showed sinus bradycardia with discernable P waves. You are manning the monitor; 1 epi given and after just one round of CPR there is ROSC. You find that you do not have P waves on the monitor with a right bundle branch block. EKG confirms Junctional rhythm. The patient begins to loose BP and heart rate. You place transcutaneous pacer set at 60, 70 mA, with good capture and sustainable BP.

In the ICU you are assisting the doctor for placement of transvenous pacemaker.

Here is an easy and simple steps to remember.

• MD will select the site for access: Preferred sites are right IJ and left subclavian
• Set up Catheters: The cordis is a 6 french catheter that comes with an dilator and guidewire. You will still need a triple lumen and accessory kit for all of the miscellaneous pieces (sutures, scalpel, needles, etc)
• Set up Pacer Generator: must be done before the pacer gets inserted into the patient; must be done over a sterile field. The non-sterile person holds the hub while the sterile person inserts the wires. The non-sterile person tightens the thumb screws. The proximal (shorter) wire inserts into the positive port (Proximal = Positive).
• When to turn on Pacer Generator: As soon as the MD secures a spot within the central venous system. Your initial settings: heart rate 80 (or well above the underlying rate so you can identify the paced rhythm), sensitivity all the way down (so the box will pace no matter what the intrinsic rhythm), and current up (20mA is a good starting place). When the doctor starts to float the balloon: 1. watch the cardia monitor for arhytmias, 2. evidence of capture (seen as a jump in the HR), 3. MD will confirm placement with an ultrasound and CXR.

Review on pacemaker modes at: https://litfl.com/pacemaker-rhythms-normal-patterns/

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