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Pacing

Working in an ICU, there are of course instances when we decide to stop aggressive measures for our patients. One of the newer nurses (to ICU) had a patient whose family decided to stop ventilation and pressors. When the patient was extubated and pressors discontinued, we began waiting for the inevitable.

The patient had a permanent pacemaker, however. While he was being supported, his heart rate was sufficient enough to not need the pacer… but when we took it away, his heart rate started to slow down, as was expected. This is when the pacer started to kick in. The nurse asked how she would know when he died (from outside the room, just looking at the monitor) if the pacemaker just kept going. We told her that sometimes the heart just stops responding to the pacer and all she would see is pacer spikes on the monitor with no resulting heart rhythm.

One of the more experienced nurses mentioned that it was possible years ago to just put a magnet over the pacemaker (which is implanted in the patient’s chest, but is usually visible as a lump under the skin) to shut it off. She then added, “But with these newfangled pacemakers, you probably have to turn it off using a computer.”

Can you imagine emailing your pacemaker to tell it what to do? That would be a bad address for the spammers to get their hands on.

Several years ago, I came to work and took report on a patient that was very close to dying. For some reason, the curtain to the room was mostly closed, and I couldn’t see the patient well. When I looked at the monitor, I saw that he had a pacemaker and had pacer spikes, as well as “capture.” Capture is when the heart responds to the pacemaker and beats accordingly. I finished getting report – the offgoing nurse said that she last checked on the patient about an hour before and he was unconscious but breathing. I decided to check on my other patient first and got caught up in doing tasks, but every time I came out to the desk, I would glance at the dying patient’s rhythm and it was always the same – pacer spike, capture.

By the time I got into his room to see him, I found that he had been dead for quite some time. He had that lifeless look about him, and the absence of respiration also tipped me off. There was of course no pulse, but up there on the monitor was a consistent and unwavering spike-capture rhythm. I learned a very important lesson that day – you can be in PEA with a pacemaker too.

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One of the most depressing things I’ve ever watched was back when I was a telemetry monitor tech. We had a patient with a DNR order, who had a pacemaker. He was declining, and family was with him, when he either threw a PE, or something similar, because all of the sudden, he said he couldn’t breathe, and slowly slipped away. His pacer kept his heart going for almost an hour, with the QRS complex getting smaller and smaller, until it finally failed to capture. I was at the monitor, watching, the entire time. I don’t know how long he had a pulse, but his heart was “responding” to the pacer for an hour. It felt almost inhumane to sit and watch that…

Thanks for this story, it reminds me that we’re moving into an era in which technology will be so highly integrated into health care that hackers, smammers and so on could literally hack, spam and phish their way into your body, yikes. Let’s hope our future pacemakers have spam blockers and anti-virus built in :)

ssssshhhhhh!

*looks both ways before continuing in a whisper*

PEA with a pacemaker? Are you trying to give the megacode people new ideas? ;-)

Thanks for the reminder. It’s good to hear from more experienced people.

Yep, PEA with a pacer. That’s why you always have to check that pulse – electronics can fool you!

Mmmm hmmm …. Remember that old adage … “Treat the patient, not the monitor!”



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  • profileI am Gina. I have been a nurse for 15 years, first in med/surg, then CVICU, inpatient dialysis, CCU and now hospice. This blog is about my experiences as a nurse, and the experiences of others in the healthcare system - patients, nurses, doctors, paramedics. We all have stories!

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