Okay, probably an easy question, but we couldn't decide amongst ourselves last night what's going to happen to the pt in question.
Pt is mid-90's, vent paced, and she's dying -- massive CVA, but not in a location that would stop her breathing, so she's essentially dying from system failure -- kidneys, GI tract are shutting down, pt's flaccid, but will open one eye to a stimulus, 100% rebreather and both O2 sats and BP are falling. Got a ventricular pacemaker no idea the manufacturer or anything beyond the fact that we see the vent spikes.
So...when our lady finally dies, are we going to just see a flat line with spikes? Will the spikes somehow know to stop firing? We've had people with implanted defibs that the doc has demagnetized to make them stop, but how can we get the flatline strip on someone who may have pacer strikes or PEA?
Aug 28, '08
You will still get spikes and QRS complexes as it is still doing its job. So what you will actually have is PEA. My suggestion is this: call the cardiologist, have them come around to turn off the pacer. Now if they're 100% pacer dependent then that will be akin to killing them. If they're not, well then by turning it off just allow nature to takes its course. In lieu of a cardiologist, I would think an ER doc wold have the know-how and wherewithal to do this. Until you turn off the pacer you will not get an asystole strip.
Hope this helps.
Aug 28, '08
Thanks, I'll pass that on to the shift tonight (I'm actually off). She's 100% pacing, and the family is waffling on the DNR -- 2 kids want to reverse it, the POA is still trying to follow mom's wishes. I don't know if we could convince them to de-energize the pacemaker, but...I'll put in a call to the chaplain, he's pretty good at explaining stuff like this to families in crisis.
Aug 29, '08
In our CCU we have a magnet that we place on the pacer for approx. 5 min. We run 2 strips in 2 different leads, pull the magnet off and continue with post motrum protocals. Its the same procedure that our Cath Lab does.
Aug 30, '08
Thanks everybody. Unfortunately, the family has reversed the DNR, so now we will essentially be coding a cadaver...
Aug 30, '08
You can have PEA with paced QRS complexes or you can have asystole with pace lines showing up. The PEA won't last long and will progress into the latter.
Edit: if the patient isn't DNR you need to be prepared to follow the pulseless ACLS algorithm, obviously. Make sure you have a pulse wave (pleth) to compare with the EKG in order to verify it isn't PEA.
Sep 11, '08
U do not need to do anything with the pacemaker...like we say in the ED...u cant pace meatloaf!
What will happen is u will have a flat line with pacer spikes. Not a big deal. Dead is dead and the pt will be pronounced.
If u place a magnet over a pacemaker, that turns the pacemaker into asynchronous mode, which will actually make the pacemaker work (there will be no difference for you since she is pacer dependent). Different models of pacemakers have different 'magnet' rates. (They all used to pace at 75bpm with a magnet, but newer models have changed that old rule of thumb....).
It also is not considered PEA because for something to be considered PEA, it has to be an electrical rhythm that should be producing a pulse. Electrical activity in and of itself isnt necessarily PEA. (Just like u wouldnt call an agonal rhythm PEA bc that is not expected to produce a pulse.)
I hope this helps!!
Apr 1, '11
Had this happen today. Our cardiologist says, "You can't turn off that pacer unless you rip it out of his chest!!!!" Now an ICD is a totally different animal all together. That can be deactivated with a magnet and same with ICD/Pacer combo, but again the pacer won't be affected just the ICD. The pacer does have to be removed if the pt is being cremated because it can explode in the crematorium.
Apr 2, '11
A magnet placed over a PM will send it to it's pre-programmed "magnet rate." As the previous poster stated, this is an asunchronous mode...meaning the PM will fire at a set rate regardless of the patients intrinsic rate. You stated the patient was 100% paced, so placing a magnet may only change the rate. Depending on the life of the battery, the rate could be 75-85 (new battery) or lower (as the battery is depleted, the magnet rate decreases). BTW, this is how PM's are checked to determine when they need to be replaced. Each company has a programmed ERI (elcective replacement interval) rate and an EOL (end of life) rate. The ERI is the initial trigger to begin thinking about a generator change. The EOL is the trigger for "change the generator ASAP" or it may stop working.
Placing a magnet over a defib will not send the PM into asynch mode. It will instead deactivate the cardiovert/defib funtion of the device. However, the PM will remain at the programmed setting. Depending on the manufacturer, you may have to leave the magnet in place the entire time or you may be able to remove it after the device "deactivates." Best bet is to have the device rep come in and re-proram the device. If you do not know the manufacturer, but have a CXR you may be able to see the device trademark on the CXR. I've actually had to do this so I know it can work.
Apr 3, '11
Agree with poster who recommended turning off the monitor. Death is determined by absence of pulse (audible or palpable), absence of BP, absence of respirations, and fixed dilated pupils.
The pacer will continue to fire but the cardiac tissue will not respond with contraction ("you can't pace meatloaf").
We do not turn off pacers in hospice...only ICDs. People die successfully with both in place with some regularity although it is not so easy with the ICDs.
I am sorry for you and the patient that the family is having a hard time accepting the realities of the human life span.
Apr 18, '11
kudos to tweedles and a few others who are taking in the whole picture. personally i was just focused on the device durng this thread and thinking =anyone curbside EP service? they program, reprogram, deprogram ,read pacers/crt devices and rarely are ever unable to get the details on a device
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