(Pacemakers): Electric Boogaloo

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© Springer Nature Switzerland AG 2020
C. G. Kaide, C. E. San Miguel (eds.)Case Studies in Emergency Medicinehttps://doi.org/10.1007/978-3-030-22445-5_47



47. Breakin’ (Pacemakers): Electric Boogaloo



Matthew Malone1   and Ashish Panchal1


(1)
Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, Columbus, OH, USA

 



 

Matthew Malone

Email: Matthew.malone@osumc.edu


Keywords

Atrioventricular blockChronic bifasicular blockAtrioventricular blockNeurocardiogenic syncopePacemakerSinus node dysfunction


Case


Syncope in a Patient with a Pacemaker


Pertinent History


This patient is a 76-year-old male who presented to a free-standing ED approximately 1 hour after a syncopal episode. He reports that he woke up this morning feeling well. This afternoon, the patient had an episode of syncope where he passed out and woke up on the floor. The episode was witnessed by his wife, who reports that he was only unconscious for a few seconds and had no seizure-like activity, confusion upon waking, tongue biting, or incontinence. Prior to his syncopal episode, he was painting the trim above a door at home. As he was painting, he became lightheaded. He had no CP, SOB, or other preceding symptoms. He did not hit his head and does not have any injuries. He is currently asymptomatic.



Past Medical History


Hypertension, Coronary Artery Disease, Complete Heart Block



Past Surgical History


Pacemaker implantation for complete heart block



Medications


Lisinopril, Atorvastatin



Social History


Remote tobacco use, no drug use, occasional alcohol use



Pertinent Physical Exam






  • BP 128/77, Pulse 80, Temp 98.1 °F (36.7 °C), RR 14, SpO2 99%.



  • HEENT: Normocephalic, atraumatic.



  • Chest Wall: Right upper chest AICD battery without overlying erythema or tenderness to palpation.



  • Neurological: Cranial nerves II-XII intact, Gross motor intact.


Except as noted above, the findings of a complete physical exam are within normal limits.


Pertinent Test Results



EKG


Paced rhythm with rate of 80 in LBBB pattern, complete capture of pacer spikes, unchanged from previous


../images/463721_1_En_47_Chapter/463721_1_En_47_Figa_HTML.png


Courtesy of Matthew Malone, MD



Laboratory Evaluation:













































































Test

Result

Units

Normal range

WBC

6.01

K/uL

3.8–11.0 103 / mm3


Hgb

13.1 ↓

g/dL

(Male) 14–18 g/dL


(Female) 11–16 g/dL


Platelets

300

K/uL

140–450 K /uL


Sodium

139

mEq/L

135–148 mEq/L


Potassium

4.0

mEq/L

3.5–5.5 mEq/L


Chloride

108

mEq/L

96–112 mEq/L


Bicarbonate

25

mEq/L

21–34 mEq/L


BUN

8

mg/dL

6–23 mg/dL


Creatinine

0.79

mg/dL

0.6–1.5 mg/dL


Glucose

92

mg/dL

65–99 mg/dL


Magnesium

2.1

mg/dL

1.6–2.6 mg/dL


Troponin

<0.01

ng/dl

< 0.11 ng/dl



CXR


Single lead pacemaker in place without evidence of lead fracture or displacement, no other acute cardiopulmonary process.



Device Interrogation


You do not have the ability to interrogate this patient’s device in your clinical setting.



Updates on ED Course


Update 1: Cardiology is consulted and returns your page. They ask you to conduct an evaluation with the patient’s assistance. The patient is asked to reproduce the movements he was performing prior to losing consciousness. While connected to a continuous cardiac monitor and with direct monitoring of the femoral pulse, he reproduces the actions of the painting above his head. The monitor demonstrates significant artifact due to movement, but it appears similar to a wide complex rhythm with a rate around 100. At this time, the patient’s palpated pulse is between 30 and 40 bpm. He reports lightheadedness and feels like he will pass out. At this time, you have the patient lie back and stop the activity.


Cardiology believes the malfunction is oversensing of muscular activity. He recommends discharge with activity precautions and expedited cardiology follow-up for adjustment of device settings.


Learning Points: Pacemaker Malfunction



Priming Questions





  1. 1.

    What are the types of pacemaker malfunction and the common underlying causes of each?


     

  2. 2.

    What is the evaluation for a patient presumed to have a pacemaker malfunction?


     

  3. 3.

    What are other common complications associated with pacemaker implantation?


     

Introduction/Background





  1. 1.

    Indications for pacemakers are numerous, but all pacemakers are placed to maintain or restore a normal heartbeat. Common indications include pacing for sinus node dysfunction, acquired atrio-ventricular block, chronic bifasicular block, pacing for atrioventricular block associated with myocardial infarction, hypersensitive carotid sinus syndrome, and neurocardiogenic syncope. Often, the necessity of permanent pacemaker implantation is driven by a nonreversible conduction abnormality associated with symptomatic bradycardia [1, 2].

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Mar 15, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on (Pacemakers): Electric Boogaloo

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