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Cardiology
Published in Faye Hill, Sash Noor, Neel Sharma, Tiago Villanueva, Medical and Surgical Emergencies for Students and Junior Doctors, 2021
Faye Hill, Sash Noor, Neel Sharma
Patients should stop offending medications such as digoxin, calcium channel blockers and beta blockers if currently prescribed. Severely symptomatic patients should undergo transcutaneous pacing. Otherwise, the treatment of choice long term is permanent pacemaker insertion.
Electricity and Magnetism
Published in Sarah Armstrong, Barry Clifton, Lionel Davis, Primary FRCA in a Box, 2019
Sarah Armstrong, Barry Clifton, Lionel Davis
Transcutaneous pacing is quicker and prevents the complications of transvenous pacing. It uses large-area skin electrodes and pulse duration of up to 50 ms to decrease nerve and muscle stimulation
Resuscitation
Published in Karim Ratib, Gurbir Bhatia, Neal Uren, James Nolan, Emergency Cardiology, 2010
Karim Ratib, Gurbir Bhatia, Neal Uren, James Nolan
Transcutaneous pacing can be easily applied, requires minimum training and avoids the risks of central venous cannulation. Many defibrillators are now equipped with external pacing facilities and it is important for those involved in managing cardiac arrest to familiarize themselves with this option. Pacing is usually carried out through self-adhesive gel pads which can also be used for defibrillation if necessary. When used for pacing, the device often additionally requires a 3-lead ECG (electrocardiogram) to be attached. The ECG gain is adjusted to ensure sensing of any intrinsic QRS complexes. The demand mode is selected and the pacing rate set to 60–90 bpm. The pacing current is set at the lowest setting and the pacemaker turned on. The current is then slowly increased, observing the patient, and monitored until electrical capture is seen. As the current increases, the skeletal muscles contract and a pacing spike is seen on the monitor. Electrical capture is recognized by wide QRS complex and a broad T wave. A current range of 50–100 mA is usually sufficient (Figure 2.3). The presence of a palpable pulse ensures electrical capture results in mechanical capture (myocardial contraction). Failure to achieve mechanical capture in the presence of good electrical capture indicates non-functional myocardium. Patients often require sedation with an IV benzodiazepine (Diazemuls) as the procedure can be painful. Transcutaneous pacing is only a temporary measure until transvenous pacing can be instituted.
Acute right ventricular myocardial infarction
Published in Expert Review of Cardiovascular Therapy, 2018
Arif Albulushi, Andreas Giannopoulos, Nikolaos Kafkas, Stylianos Dragasis, Gregory Pavlides, Yiannis S. Chatzizisis
Maintaining adequate atrioventricular synchrony is a basic component in optimizing right ventricular preload. It is important to know that the infarcted RV and, consequently, the preload-deprived LV have a fixed stroke volume, and in this circumstance, cardiac output mainly depends on the heart rate [73,74]. Atropine can increase heart rate to some extent, but patients with profound bradyarrhythmias likely need a pacemaker [75]. Patients with RVMI and atrioventricular block should have a temporary dual-chamber pacemaker implanted, as it helps increasing the cardiac output and preventing the development of cardiogenic shock to a greater extent than a single chamber pacemaker [76]. Transcutaneous pacing can be also considered when the transvenous pacing cannot be adequately sensed by the infarcted RV.
Takotsubo cardiomyopathy in the setting of complete heart block
Published in Baylor University Medical Center Proceedings, 2018
Aasim Afzal, John Watson, James W. Choi, Jeffrey M. Schussler, Manish D. Assar
The condition CHB, also known as third-degree atrioventricular (AV) block, is when none of the atrial impulses reach or are conducted through the AV node. Etiologies include both reversible and irreversible causes and both congenital and acquired conditions, including iatrogenic causes such as medications or cardiac surgery, acute myocardial infarction, infiltrative or degenerative processes such as sarcoidosis or amyloidosis, rheumatic diseases, infection, metabolic or electrolyte disturbances, neuromuscular disorders, and toxins. However, many cases have been deemed idiopathic. The estimated prevalence of CHB is 0.04% worldwide and 0.02% in the USA.6 In 2008, the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society developed guidelines for placement of devices for the management of CHB,7 citing evidence that a permanent pacemaker improves survival in those with irreversible CHB, especially after syncope.8–11 Thus, the placement of a permanent pacemaker is a class I recommendation (level of evidence: C).7 Initial in-hospital management of a patient with CHB revolves around ensuring hemodynamic stability. Patients who are hemodynamically stable at presentation are often monitored on telemetry with transcutaneous pacing pads in place, pending the placement of a temporary pacing wire or permanent pacemaker. However, patients with hemodynamic instability will often need a transvenous pacing wire placed emergently. Medical management is strictly reserved for special cases in which the level of AV block occurs at the AV node and is thought to be secondary to a reversible cause. In these cases, sympathomimetic agents such as isoproterenol can be used to ensure a sufficient ventricular rate.
Prehospital Protocols for Post-Return of Spontaneous Circulation Are Highly Variable
Published in Prehospital Emergency Care, 2021
M. F. Spigner, J. L. Benoit, J. J. Menegazzi, J. T. McMullan
Primary measures are reported in Table 1. Most protocols recommended 12-lead ECG acquisition or the use of vasopressors. Among the protocols that recommended vasopressors, 21% [CI 11–33%] offered push-dose epinephrine as an alternative to continuous infusions. The inclusion of antiarrhythmic medications or transcutaneous pacing was not common. Prehospital cooling was present in 25 protocols (33% [CI 23–45%]).