External generator: Shows rate (bpm), output (mA) and sensitivity
Cordis Kit (7 Fr): Gold strip on kit at Harbor. Contains cordis introducer sheath, TV pacer catheter and pacer wire sheath
Sheath size (internal diameter) should match pacer wire size (external diameter). Otherwise you will get leakage!
Sheath size (internal diameter) should match pacer wire size (external diameter). Otherwise you will get leakage!
Test small balloon for leaks prior to insertion with 1.5mL of air while balloon rests in a container of saline
Connect the positive and negative electrodes to the external generator
Advance the catheter through the introducer sheath and into cordis hub to roughly 20 cm (catheter has marked bars indicating 10cm)
Pearl - Digital generators have "emergency" button that goes to automatic settings
Blind approach: Monitor shows pacer spikes followed by a widened QRS (LBBB appearance)
Ultrasound approach: Have assistant give a subcostal/parasternal long axis, which gives visualization image of when electrode contacts final resting position
Sensing approach: Use alligator clip to connect negative pacer electrode to any precordial lead. Look for ST elevation when RV endocardium engaged.
Fluoroscopy: If time permits, use this method in a patient that has prior pacemaker/ICD. Placement of TV pacer with out fluoro can disrupt prior electrode placements.
Take note of pacer wire depth in case it is accidentally moved
If you overshot your mark (ie IVC/Pulm artery), deflate balloon and pull back. DO NOT PULL INFLATED BALLOON BACKWARD THROUGH A VALVE.
Pearl - IVC pacing leads to coughing/hiccuping and ventilator alarms (ie high frequency)
Lock sheath onto cordis hub and then fully extend it & curl around while holding pacer wire in place. Sheath gives sterile amount of wire for any future adjustments if needed.
Additional sutures can be placed to stabilize it
Output: Determine threshold level by reducing electrical current settings until capture lost. Final current set to twice the threshold level for pt
Sensitivity: Adjust level (not too high or too low) so it allows intrinsic beats (unless you are overdrive pacing), but supplements it if needed. You do not want oversensing or undersensing.
Good to obtain baseline CXR, which should show the catheter tip over the inferior border of the cardiac shadow
ECG shows paced QRS exhibiting a LBBB morphology, and a superior QRS axis
Transvenous pacing
Transcutaneous pacing
Synchronized cardioversion
Vagal maneuvers
Defibrillation
Pericardiocentesis
Thrombolytics for STEMI
Double simultaneous external defibrillation