Being able to competently float a transvenous pacemaker is the mark of a resuscitationist. This procedure can be life-saving, but it requires a diligent regime of knowledge retention and a department with good clinical logistics. In this EMCrit Episode, I go through the procedure in intricate detail–by the end of it, you will be exposed to all aspects of pacemaker placement.
Indications
- Unstable Bradycardia (2nd Degree II or 3rd Degree Heart Block)
- Sick Sinus with Pauses
- Overdrive Pacing for unstable tachydysrhythmias, especially Torsades de Pointes (polymorphic VT due to long QT)
- Sometimes: Prophylactic for new LBBB or RBBB with left axis deviation due to acute MI (Ideally in the cath lab) [PMID 4682667]
Discussion of Stable High Degree Heart Blocks
Site
- RIJ >> L Subclav >> LIJ >> R Subclav >> Femoral
Box Management
Box is almost always Medtronic 5392
Starts up in DOO at 25 mA or Push Emergency
If you turn down Atrial to zero when it starts up, it will turn to VVI
remember PSI-pace, sense, action for the 3-letter convention
You have 24-hrs from warning to failure (but don't wait). The machine has 15 seconds of stored power to change the battery.
Procedure for Blind Placement
You need a mechanical capture monitor
- pulse ox
- art line
- POCUS Pulse
Equipment
- You really want a kit–I recommend: Argon 008566A
- Sterile Central Line Bundle
- Sterile Gloves
- Pacemaker Box/Generator
- Wire (Disposables are the way to go)
The Float:
- Introducer Sheath is in (If the patient NEEDS a pacemaker–an experienced person should put in the introducer)
- Position the Patient so you can see the monitor
- Put the damn sterile sheath on the wire
- Test the balloon (Special Syringe only allows 1.5 ml of air)
- Attach to wire extender to the box, the pacemaker pins and tighten!!!! (Write Negative=Distal on your Pacemaker Drawer)
- Have your partner set the box. Rate 2x intrinsic and V Output 20 mA
-
Orient the curve
- Advance to 15 cm
- Call for balloon up (Note be GENTLE with balloon inflation/and only passive deflation. Down until 1.3 cc)
- Advance somewhat rapidly until your mech capture method shows capture (ECG is a hint, but don't rely on it)
- Do the turn down dance
- Deflate Balloon/lock stopcock
- Secure by first clamping down on the wire then attaching down distal and clamping proximal portions of sheath and suture the introducer to the patient
- Hang box on IV pole
- Check Sensitivity Settings
- Get an Xray (RV placement will show the wire cross the midline)
- Place in VVI
If you hit 50 cm (unless they are really tall) consider pulling back and starting again
Point of Controversy: Do you need to deflate the balloon when pulling back to try again?
Turn Down Dance
20 >> 15 >> 10 >> 5 >> 3 >> 2 >> 1 >> Deflate >> Have them Cough (Pre-Covid) = Win (2.5-3x threshold)
Really want to be < 1 mA threshold
How to Deal with It Not Going Where You Want it To
- Ultrasound
- LL Decubitus [10.1016/j.ajem.2017.11.057]
- Digital X-Ray as Crappy Fluoro
Sensitivity Adjustment
- Need to pause or be less than patient's intrinsic rate and turn down to 0.1 mA
- Sensitivity is backwards (when you go higher it is less sensitive)
- You are building a wall–this analogy from Dr. Sarah Wesley
- Want to be able to see the QRS but not see T-Waves
- Defaults to 2 mV
- Turn up the mV (counter-clockwise) until you stop seeing sensing
- Then turn numbers down until you see sensing (clockwise)
- then half that number
- Rarely need to adjust unless there is a problem
Radiographs/Going Upstairs
- Someone with their hand on the neck during all movement
- Replace box and wires
Floating while TransCut Pacing is Going On
- Only look at mech capture
- Sedate if necessary
- Set rate 2x transcut rate
ECG Float
Attach negative lead to V1 and attach the limb leads
atrium=large ps
above atrium p and qrs neg
p becomes positive in low atrium and ventricle
ECHO Float
Complications
- Infection
- Perforation
- Looping of Catheter
- Dysrhythmia
Crash Troubleshooting
- Is the wire connected to the box
- Is the box connected to the pacemaker
- Are the pin interfaces pushed all the way in
- Is the pacemaker still in at same depth
- Is the box powered with appropriate settings (Consider just pressing Emergency)
- Consider changing out the wire
- Consider pushing pacing wire in a little bit if you see pacing spikes but no capture
- Get transcutaneous pacemaker and put on the pads
- Grab Epi Drip and Push-Dose
Video on Setting Up the Argon Kit
Additional New Information
More on EMCrit
Just-In-Time (JIT) Resources
Additional Resources
- Sarah Wesley from Bedside Critical Care
- Brit Long Review Paper – transvenous-pacer-placement
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Now on to the Podcast
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Scott, great stuff as always. Happened to be writing a lecture on this topic myself this week – those ECG images can be found in Roberts and Hedges and initially appeared in / they reference NEJM (1972, 287: 651).
Video was super helpful. RNs actually asked for some education on this just last week (which is great given I am Med Dir in a 5 bed CAH in rural ID. I was dumfounded (and grateful) we stocked the Argon kits (and one of the 2 was expired so it was Christmas time!). We have the Medtronic model 53401 which as best I can tell is ever more idiot friendly with just one input and default s to VVI (no a-hole 🙂 ). It has atrial cables which i’m thinking of duct taping the shit out and slapping some Biohazard… Read more »
So glad Sean!!!
Thx Scott. now if you could just get your buddies at Argon to use those blue syringes that you just thread the wire through! i remember during residency at Bellevue when those bad boyz came out- so so cleaver. happy thanksgiving
hey Sean
gotta say I won’t let my residents train with those
learning to be able to maintain needle stability in-vessel with syringe disconnect and wire manipulation is an absolute core microskill
but i take your meaning, brother
super cool Scott… an awful lot of info, but I “loved every minute of it”. I need to hear Sara Wesley’s lecture. it’s funny.. I’m an impatient fellow, and I often consider upping the speed of the pod to 1.25 or higher, but it never works… you’re already at 1.5 speed normally. Love it. one mea culpa. despite years of practice, and a fault of my training, I never placed a transvenous pacer. I listened to his blog twice, watched many others, but the thought of my first when it’s needed slightly petrifies me. thanks for making it less petrifying… Read more »
in oversensing, the sensing light will flash twice for each QRS.
Hey Scott–Great pod and video. I teach this in SIM to my residents every year, but I learn new tips every year. We probably do 20+ TVPs every year. Appreciate the discussion of the turn-down dance, we have never done it quite like this, I will start integrating this into our practice. Thanks again.