BBB and ST elevation after pacer insertion...

[miss81, BSN, RN]

In my hospital CCU RN's monitor all tele for the rest of the hospital. Last evening a patient who was admitted with 1st and 2nd degree block and had a pacer (not sure of the type of pacer) inserted that day was tracing sinus tachycardia. By midnight I noticed the rhythm would have runs of something that resembled a bundle branch block with some ST elevation. Then the patient stayed in that rhythm. I called the floor and the RN there completed an EKG and called the resident. Meanwhile, I assessed the patient who was completely asymptomatic. (He actually tapped me on the butt with the TV remote and told be not to fool up his discharge for the am... but that is a whole other thread! ). The resident ordered a set of common labs and cardiac enzymes. All were fine, except CPK which we expected to be elevated since he had a pacer inserted that day. The EKG showed a bundle branch block (I believe LBBB, but I can't remember the exact leads so I can't be positive). Upon reviewing his old EKG's he had never had that before. The patient then converted to a 1 degree AV block and then finally in a paced rhythm. The resident stated that because the patient was asymptomatic he did not need any other interventions, although he really didn't know what was happening or what to do about it!

Ok, so my questions are regarding the BBB after a pacer insertion. I did a little research and (without going into too much detail) found once article that discussed a case where the pacemaker wires were not in proper position in the heart and this caused a BBB. Anyone have any experience with this? Is it common? What are the repercussions?

Thanks!

[Biffbradford]

Lead placement would be my thought as well. I understand that you might not know, but the pacer settings would be nice to know. Pacer only, or did it have a defib? I imagine the patient had something worse than a BBB going in to his pacer insertion, so which would you rather have?

[nerdtonurse?, BSN, RN]

I've seen patients pop in and out of BBB after insertion (my gut tells me it's the heart reacting to the presence of the pacer leads...). When we've had BBB that occurs post pacer, it usually clears up by discharge, and I've never seen anyone get symptomatic. Of course, having said that, I'll just go ahead and get the temporary pacer kit out and put it by my computer on my next shift, since I've probably jinxed the whole place....

Now, if the pt's not wearing the sling, and you think the pacer may have shifted, I'd call and get the MD to order a CXR on those grounds -- pt movement may have dislodged leads.

[miss81, BSN, RN]

Thanks guys!

Now, if the pt's not wearing the sling, and you think the pacer may have shifted, I'd call and get the MD to order a CXR on those grounds -- pt movement may have dislodged leads.

On that note, our pt's never wear a "sling." We just tell them not to lift their arm above their head. Maybe we should be though!

What else would I be looking for to tip me off that the pacer may have shifted? Would the pt not go into a true paced rhythm then?

[nurseprnRN, BSN, RN]

where is it pacing? if you have a dual-chamber pacer, one lead senses (and then paces, if it isn't making p waves fast enough) the atria, then the ventricular lead waits to see if the (sensed or paced) impulse is transmitted through the av node to the ventricles-- if yes, then the ventricular lead does nothing and waits for the next beat; if no, it paces the ventricle.

the qrs you get from a ventricular lead looks like bbb, because it isn't going through the normal av node-to-bundles pathway-- it starts where it gooses the rv and then spreads throughout the ventricles via the myocardium, so it might look like the abnormal conduction it is;). could it be that you were seeing ventricular paced beats? sometines the pacer spikes are really small in some leads. if you couldn't see a pacer spike before each qrs complex, look at it in a different lead to be sure.

[tswim]

First, I agree with GrnTea... the monitors do not always show pacing spikes unless they are set to search for them, so pacing can look like BBB or PVCs.

Second, if the patient were truly having LBBB, the ST elevation would be useless for analysis as you cannot diagnose hemiblock, infarction, or ischemia in the presence of LBBB.

[CCL RN, RN]

Thanks guys!

On that note, our pt's never wear a "sling." We just tell them not to lift their arm above their head. Maybe we should be though!

What else would I be looking for to tip me off that the pacer may have shifted? Would the pt not go into a true paced rhythm then?

The sling is a standard of care. We place them on our patients immediately after the procedure (while they are still on the table). Maybe you should talk with your educator and see about changing your procedures post pacer placement?

[casi, ASN, RN]

My first thought is the pacer leads could have caused some irritation in the heart hence a change in rhythm for a little bit

Otherwise make sure his tele is set to look for a pacemaker. Oftentimes a ventricularly paced rhythm looks like a BBB.

[miss81, BSN, RN]

Thanks you all for your responses. Made me think about possibilities that I didn't think about. Critical care is fairly new to me... I worked a lot of surgery and OBS, so I'm still learning. The monitor was set to detect pacing. The rhythm had the "M" shaped "bunny ears" and so did the EKG (I believe in at least v5 and v6).

The sling is a standard of care. We place them on our patients immediately after the procedure (while they are still on the table). Maybe you should talk with your educator and see about changing your procedures post pacer placement?

The pacers are not placed here at our hospital. The pt's are transported to another hospital for his (there is only one in my province that places pacers) and I guess it's not there policy. We just recently had approval of a NEW post pacer teaching policy and it onoy mentions not putting your arm over your head for two weeks and not lifting. However, I will speak to her about it... good suggestion!