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Pacemakers 12/04

1-What is a pacemaker? 2- What does “intrinsic” mean? 3- How exactly do pacemakers work on the heart? 4- What are the parts of a pacemaker? 5- Are there different kinds of pacemakers? 6- What is the advantage of two wires over one? 7- How are pacemakers inserted? 8- What do they mean by transvenous, transcutaneous, and transthoracic? 9- How does the generator box work? 10- How long do the implanted batteries last? 11- How much electricity does the pacemaker use to actually pace the heart? 12- In English, please? 13- What is “capture threshold?” 14- Why do paced beats generated by a ventricular wire look like PVCs? 15- What does “asynchronous” mean, and what does “demand” mean? 16- What do those letters: VVI, DDD, etc. stand for? 17- What is “failure to capture?” 18- What is “failure to sense”? 19- How can an implanted pacemaker be reprogrammed? 20- What is the magnet thing? 21- What are some reasons for placing a permanent pacemaker? 22- What is an AICD? 23- Can AICD’s also function as pacemakers?
24- What problems do AICD’s have? 25- How do you stop an AICD from shocking the patient incorrectly? 26- Can you shock a patient with a pacemaker? 27- What is external cardiac pacing? 28- Who was Zoll, anyhow? 29- What else do I need to know about running the external pacemaker? 30- How do I know if capture has been achieved? 31- What’s the tricky part? 32- Does external pacing hurt? 33- How long can a person stay on the external pacemaker? 34- How does the Zoll go into demand mode? 35- Any other Zoll tricks? 36- Can you do CPR with the external pacer in place? 37- How effective is the Zoll?


What is a pacemaker?

A pacemaker is an electronic device that provides an electrical signal to make the heart beat when it’s own, built-in pacemakers fail. The anatomical, built-in pacemakers provide what’s called the “intrinsic” rhythm, and they can be disrupted by various conditions – ischemia for example, or by an MI.

What does “intrinsic” mean?

Intrinsic means “built in”. In this situation, it means: “coming from the patient’s own built-in, natural pacemakers” : the SA or AV nodes; or sometimes from lower down in the ventricles.

How exactly do pacemakers work on the heart?

The pacemaker essentially does two things : it senses the patient’s own rhythm using a “sensing circuit”, and it sends out electrical signals using an “output circuit”. If the patient’s intrinsic rhythm becomes too slow or goes away completely, the electronic pacemaker senses that, and starts sending out signals along the wires leading from the control box to the heart muscle. The signals, if they’re “capturing” properly, provide a regular electrical stimulus, making the heart contract at a rate fast enough to maintain the patient’s blood pressure.

Here’s the “box”, implanted.

How many pacing wires?

What are the parts of a pacemaker?

The pacemaker box itself is called the “pulse generator” – the generator is connected to either one or two wires, which carry the electrical signals to the heart muscle. Permanent pacing generators are implanted in the chest under the skin – nowadays they’re very small – and the wires leading to the heart are threaded through the subclavian vein.

Are there different kinds of pacemakers?

Pacemakers can be either temporary or permanent. The temporary pacemakers that we see in the MICU are made up of a control box and one single output wire leading to the inner wall of the RV (thus called a ventricular wire, or “V-wire”), and provide simple rate control by pacing the ventricles. Permanent pacemakers come in several flavors, but the main difference between them is that some have only one wire leading to the RV, and some have two – one to the right atrium (RA), and another one to the RV. A pacing system that paces both the RA and the RV is called an “atrioventricular” pacer, and paces both right heart chambers in sequence. The signal affects the left-side chambers and stimulates them to contract as well. The signal from the wire generates a visual signal on the EKG that looks like, and is called a “spike”.

Here’s an example of a temporary, external, single-wire pacing box. The wire has two pole connections, so one pair of connectors: single wire box.

Here’s a nice example of single-wire pacing, with spikes coming at a rate in the 70’s. The reason we can tell that there’s only one wire going is simply that there’s only one spike. Two-wire systems generate two spikes.

How many spikes this time?

Two sets of connectors: two wires. So what kind of box is this?…...

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