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47. Breakin’ (Pacemakers): Electric Boogaloo
Keywords
Atrioventricular blockChronic bifasicular blockAtrioventricular blockNeurocardiogenic syncopePacemakerSinus node dysfunctionCase
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
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.
What are the types of pacemaker malfunction and the common underlying causes of each?
- 2.
What is the evaluation for a patient presumed to have a pacemaker malfunction?
- 3.
What are other common complications associated with pacemaker implantation?
Introduction/Background
- 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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