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THE HEART'S CONDUCTION SYSTEM AND "NATURAL PACEMAKER “

The heart has its own built-in electrical system, called the conduction system. The
conduction system sends electrical signals throughout the heart that determine the timing
of the heartbeat and cause the heart to beat in a coordinated, rhythmic pattern. The
conduction system stimulates precise contractions of the heart's chambers to ensure that
blood is pumped effectively.

The electrical signals, or impulses, of the heart are generated by specialized tissue
called the sinoatrial (SA) or sinus node .The sinus node is sometimes called the heart's
"natural pacemaker." Each time the sinus node generates a new electrical impulse; that
impulse spreads out through the heart's upper chambers, called the right atrium and the
left atrium. This electrical impulse stimulates the atria to contract, pumping blood into the
lower chambers of the heart (the right and left ventricles).

The electrical impulse then spreads to another area of specialized tissue located
between the atria and the ventricles, the atrioventricular (AV) node. The AV node
momentarily slows down the spread of the electrical impulse, to allow the left and right
atria to finish contracting.

From the AV node, the impulse spreads into a system of specialized fibers called
the bundle of His and the right and left bundle branches .These fibers distribute the
electrical impulse rapidly to all areas of the right and left ventricles, stimulating them to
contract in a coordinated way. With this contraction, blood is pumped from the right
ventricle to the lungs, and from the left ventricle throughout the body

AIMS OF PACEMAKERS

 To maintain an adequate heart rate.

 To treat arrhythmias.
 To reduce the risk of heart block

.COMPONENTS OF PACEMAKERS

PULSE GENERATOR
Battery cells power pulse generator. Lithium batteries lasting 6 years or more are
used in most pacemakers. Nuclear powered pacemakers (Plutonium238 source) can last
20 years or more. Other pacemakers can have their batteries recharged; externally when
the generator battery fails the implantable unit that contains the batteries must be replaced
surgically.
The Pulse generator has several controls. They are energy output, heart
rate and pacing node.

ENERGY OUTPUT
It refers to the intensity of the electrical impulse delivered by the pulse generator
to the myocardium. The amount of out put is measured in milliampers(M.A).The MA
setting is regulated by the physician at the time of pacemaker incersion and is set at the
lowest level that will produce depolarization .A setting of 1.5 MA usually is sufficient to
cause depolarization.
HEART RATE
Heart rate is set according to the desired therapeutic aim and the clinical
consideration of the patient. heart rate is usually set at70-80 beats/minute. If the purpose
of pacemaker is to suppress dysarrhythmias the rate is set higher often 100-
200beat/minute.

INDICATIONS OF ARTIFICIAL PACEMAKERS

1. Adams Strokes Attack (Syncope secondary to third degree AV Block).

2. Thrid degree AV Block with slow ventricular rate.
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3. Acute myocardial infraction with Mobitz A V Block.

4. Right bundle branch block plus left anterior hemi block or left posterior hemi block
(particularly Acute MI).

5. New left bundle branch block associated with acute MI

6. Symptomatic Sinus bradicardia unresponsive to medical therapy.

7. Atrial fibrillation with slow ventricular in the patient who requires digitalis therapy.

8. Carotid sinus syncope.

9. Suppression of dysarrythmias (atrial or ventricular tachydysarrhythmias)

10. Dysarrythmias occurring during or after cardiac surgery.

11. Sick sinus Syndrome.

12. Prophylaxis before surgery in patients with history of cardiac arrest or A V block.

TYPES OF PACEMAKER

Types of pacemakers — A variety of types of pacemakers have been developed to restore

or sustain a regular heartbeat in different ways.

 Demand pacemakers monitor the heart's natural electrical activity and discharge
only when the heart's own rate is too slow or the heart misses a beat.
 Fixed-rate pacemakers discharge impulses at a single, steady rate, regardless of
the heart's own electrical activity.
 Rate-responsive pacemakers are designed to raise or lower the heart rate to help
meet the body's needs during physical activity or rest. These devices also work on
“demand.”

Pacemakers may also be single, dual, or triple chambered:

 Single-chamber pacemakers have one lead to carry impulses to and from either
the right atrium or right ventricle.
 A dual-chamber pacemaker usually has two leads, one to the right atrium and
one to the right ventricle, which can allow a heart rhythm that more naturally
resembles the normal activities of the heart.
 Triple-chambered pacemakers typically have one lead in the right atrium, one
to stimulate the right ventricle, and one to stimulate the left ventricle. These
pacemakers are inserted in patients who have weakened heart muscle (which
results in heart failure). These pacemakers "resynchronize" the ventricles and may
improve the efficiency of the contraction of the heart, improving its blood flow.

TYPES OF PACING

TEMPORARY PACEMAKERS — Temporary pacemakers are intended for short-term

use during hospitalization. They are used because the arrhythmia is expected to be
temporary and eventually resolve, or because the person requires temporary treatment
until a permanent pacemaker can be placed.

Temporary induction site

1. Subclavian vein
2. Antecubital vein

3. Femoral vein

4. Jugular vein
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Temporary pacing method

Temporary pacemakers are used in the following situations;

1. Emergency treatment of Ventricular Standstill.

2. Short treatment of conduction defects causing decreased CO

3. Prophylactic management of persons who are prone to the sudden development of

complete heart block.

A temporary spacing system is characterized by an external pulse generator attached to

the distal end of the venous system, to make contact with the endocardial or epicardial
surface

If the patient is connected to a cardiac monitoring the presence of spacing stimulus (a

small vertical spike that indicate that the pulse generator has send a stimulus to the heart)
and evidence that the stimulus actually causes depolarization will be noted.

The pulse generator secured to an arm of the anticubital fossa , which is the insertion site
of the pacing catheter.If the subclavian site is used the pulse generator may be tapped to
the chest or placed on specially prepared hospital gown.

GUIDELINES FOR CARE OF PATIENTS WITH TEMPORARY PACEMAKERS

1. Assessment of pacemaker function

o Assess the heart rate

If the patient is connected to cardiac monitor ;

o Monitor the presence of pacing stimulus that a P wave or QRS complex

immediately follows the stimulus
o Maintenance of system integrity

2. Ensure that the catheter terminals are securely connected to the pulse generator.

 Ensure that pulse generator is attached to the client in such way that accidental
dislodgement of the system does not occur.

 Maintenance of safety and comfort.

3. Assess for signs of infection at catheter insertion site.

4. Encourage range of motion in extremely to which pulse generator is attached as

permitted.

5. Ensure that patients avoids any contact with electrical machinery that is not properly
grounded.

6. Explain the purpose of pacing system and any prescribed restrictions on physical
activity to prevent anxiety.

PERMANENT PACEMAKERS — Permanent pacemakers are used in long term

treatment of persistent dysarrhythmias that are amenable to type of therapy .The pacing
system is totally implanted with the generator generally placed in subcutaneous pocket
beneath the clavicle .The catheter may be placed in contact with the heart by transvenous
or epicardial approach.
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Permanent pacemakers are inserted in the operating room or in special procedure

room .A battery that has an expected life to 4 to 10 years powers the generator.

Manipulation of heart rate and energy output has been difficult.

Immediate post insertion care of person with a permanent pacemaker includes

monitoring for infection and assessment of systems functioning . Attaching the person to
cardiac monitor for 24-48 hours following insertion to the usual practice

PACEMAKER FUNCTION

A pacemaker consists of a battery, a computerized generator, and wires with

electrodes on one end. The battery powers the generator, and a thin metal box surrounds
both it and the generator. The wires connect the generator to the heart.

The pacemaker's generator sends the electrical pulses that correct or set the heart
rhythm. A computer chip figures out what types of electrical pulses to send to the heart
and when those pulses are needed. To do this, the computer chip uses the information it
receives from the wires connected to the heart. It also may use information from sensors
in the wires that detect the movement, blood temperature, breathing, or other factors that
indicate the level of physical activity. That way, it can make the heart beat faster when
exercise.

The computer chip also records the heart's electrical activity and heart rhythms.
According to these recordings pacemaker works better at making sure that normal heart
rhythm.The doctor can program the computer in the pacemaker without having to use
needles or directly contacting the pacemaker.

The wires in the pacemaker send electrical pulses to and from the heart and the
generator. Pacemakers have one to three wires that are each placed in different chambers
of the heart.

The wires in a single-chamber pacemaker usually carry pulses between the right
ventricle (the lower right chamber of the heart) and the generator.

The wires in a dual-chamber pacemaker carry pulses between the right atrium and
the right ventricle and the generator. The pulses help coordinate the timing of these two
chambers' contractions.

The wires in a triple-chamber pacemaker are used for heart muscle weakness and
carry pulses between an atrium and both ventricles and the generator. The pulses help
coordinate the timing of the two ventricles with each other.

METHODS OF PACING

Percussive pacing

Percussive pacing, also known as transthoracic mechanical pacing, is the use of

the closed fist, usually on the left lower edge of the sternum over the right ventricle in the
vena cava, striking from a distance of 20 – 30 cm to induce a ventricular beat (the British
Journal of Anesthesia suggests this must be done to raise the ventricular pressure to 10 -
15mmHg to induce electrical activity). This is an old procedure used only as a life saving
means until an electrical pacemaker is brought to the patient

Transcutaneous pacing

Transcutaneous pacing (TCP), also called external pacing, is recommended for

the initial stabilization of hemodynamically significant bradycardias of all types. The
procedure is performed by placing two pacing pads on the patient's chest, either in the
anterior/lateral position or the anterior/posterior position. The rescuer selects the pacing
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rate, and gradually increases the pacing current (measured in mA) until electrical capture
(characterized by a wide QRS complex with a tall, broad T wave on the ECG) is
achieved, with a corresponding pulse. Pacing artifact on the ECG and severe muscle
twitching may make this determination difficult. External pacing should not be relied
upon for an extended period of time. It is an emergency procedure that acts as a bridge
until transvenous pacing or other therapies can be applied.

Epicardial pacing (temporary)

ECG rhythm strip of a threshold determination in a patient with a temporary

(epicardial) ventricular pacemaker. The epicardial pacemaker leads were placed after the
patient collapsed during aortic valve surgery. In the first half of the tracing, pacemaker
stimuli at 60 beats per minute result in a wide QRS complex with a right bundle branch
block pattern. Progressively weaker pacing stimuli are administered, which results in
asystole in the second half of the tracing. At the end of the tracing, distortion results from
muscle contractions due to a (short) hypoxic seizure. Because decreased pacemaker
stimuli do not result in a ventricular escape rhythm, the patient can be said to be
pacemaker-dependent and needs a definitive pacemaker.

Temporary epicardial pacing is used during open heart surgery should the surgical
procedure create atrio ventricular block. The electrodes are placed in contact with the
outer wall of the ventricle (epicardium) to maintain satisfactory cardiac output until a
temporary transvenous electrode has been inserted.

Transvenous pacing (temporary)

Transvenous pacing, when used for temporary pacing, is an alternative to

transcutaneous pacing. A pacemaker wire is placed into a vein, under sterile conditions,
and then passed into either the right atrium or right ventricle. The pacing wire is then
connected to an external pacemaker outside the body. Transvenous pacing is often used
as a bridge to permanent pacemaker placement. It can be kept in place until a permanent
pacemaker is implanted or until there is no longer a need for a pacemaker and then it is
removed.

Permanent pacing

Right atrial and right ventricular leads as visualized under x-ray during a
pacemaker implant procedure. The atrial lead is the curved one making a U shape in the
upper left part of the figure.

Permanent pacing with an implantable pacemaker involves transvenous placement

of one or more pacing electrodes within a chamber, or chambers, of the heart. The
procedure is performed by incision of a suitable vein into which the electrode lead is
inserted and passed along the vein, through the valve of the heart, until positioned in the
chamber. The procedure is facilitated by fluoroscopy which enables the physician or
cardiologist to view the passage of the electrode lead. After satisfactory lodgement of the
electrode is confirmed the opposite end of the electrode lead is connected to the
pacemaker generator.

IMPLANTATION — The pulse generator of a permanent pacemaker is implanted into

soft tissue beneath the skin, which is known as prepectoral implantation; this is located
under the skin and fat tissue but above the pectoral or breast muscle. The pacemaker
leads are typically inserted into a major vein (transvenously) and advanced until the
electrodes are secured within the proper region(s) of heart muscle. The other ends of the
leads are attached to the pulse generator .

Less commonly, the pulse generator is placed under the skin of the upper
abdomen.

Generally the pacemaker is implanted in a sterile laboratory or operating room by

a specialist (cardiologist, surgeon, or cardiac electrophysiologist) with experience in this
procedure. Local anesthesia is used to make the procedure as pain-free as possible. In
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some cases, sedation or even general anesthesia may be used. The position of the
pacemaker leads is usually checked using X-ray imaging (called fluoroscopy). The length
of the procedure depends upon the type of device being placed.

Recovery from the procedure is rapid, but there may be some restrictions on arm
movement and activities for the first few weeks. Lead dislodgement is more common in
the first few weeks after implantation. The hospital stay is usually brief, and in some
cases the procedure can be done as a day surgery. Uncommon but possible risks
associated with permanent pacemaker implantation include collapsed lung
(pneumothorax), infection, and bleeding.

Once implanted, pacemakers can be programmed to change the baseline heart

rate, the upper heart rate at which the pacemaker will pace, and heart rate changes that
should occur with exercise

NURSES RESPONSIBITITY- PACEMAKER

PREOPERATIVE CARE
 Provide routine preoperative care and teaching
 Assess knowledge and understanding of the procedure, clarifying and expanding on
existing knowledge as needed.
 Clarifying knowledge, providing information, and conveying emotional support
reduces anxiety and fear and allows the client to develop a realistic outlook regarding
pacer therapy.
 Place ECG monitor electrodes away from potential incision sites. This helps preserve
skin integrity.
 Teach range-of-motion (ROM) exercises for the affected side. ROM exercises of the
affected arm and shoulder prevent stiffness and impaired function following
pacemaker insertion.

POSTOPERATIVE CARE
 Provide postoperative monitoring, analgesia, and care
 Obtain a chest X-ray as ordered. A postoperative chest X-ray is used to identify lead
location and detect possible complications, such as pneumothorax or pleural effusion.
 Position for comfort .Minimize movement of the affected arm and shoulder during
the initial postoperative period. Restricting movement minimizes discomfort on the
operative side and allows the leads to become anchored, reducing the risk of
dislodging.
 Assist with gentle ROM exercises at least three times daily, beginning 24 hours after
pacemaker implantation. ROM exercises help restore normal shoulder movement and
prevent contractures on the affected side.
 Monitor pacemaker function with cardiac monitoring or intermittent ECGs. Report
pacemaker problems to the physician:
 Failure to pace. This may indicate battery depletion, damage or dislodgement of pacer
wires, or inappropriate sensing.
 Failure to capture (the pacemaker stimulus is not followed by ventricular
depolarization). The electrical output of the pacemaker may not be adequate, or the
lead may be dislodged.
 Improper sensing (the pacemaker is firing or not firing, regardless of the intrinsic
rate). This increases the risk for decreased cardiac output and dysrhythmias.
 Runaway pacemaker (a pacemaker firing at a rapid rate). This may by due to
generator malfunction or problems with sensing.
 Hiccups. A lead positioned near the diaphragm can stimulate it, causing
hiccups.Hiccups may occur in extremely thin clients or may indicate a medical
emergency with perforation of the right ventricle by the pacing electrode tip.
 Assess for dysrhythmias and treat as indicated. Until the catheter is “seated” or
adheres to the myocardium, its movement may cause myocardial irritability and
dysrhythmias. Fibrotic tissue develops within 2 to 3 days.
 Document the date of pacemaker insertion, the model and type, and settings. This
information is important for future reference.
 Immediately report signs of potential complications, including myocardial
perforation, cardiac tamponade, pneumothorax or hemothorax, emboli, skin
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breakdown, bleeding, infection, endocarditis, or poor wound healing . Early

identification of complications allows for aggressive intervention.
 Provide a pacemaker identification card including the manufacturer’s name, model
number, mode of operation, rate parameters, and expected battery life. This card
provides a reference for the client and future health care providers.

HOME CARE
Provide appropriate teaching for the client and family about:
 Placement of the pacemaker generator and leads in relation to the heart.
 How the pacemaker works and the rate at which it is set.
 Battery replacement. Most pacemaker batteries last 6 to 12 years. Replacement
requires a outpatient surgery to open the subcutaneous pocket and replace the battery.
 How to take and record the pulse rate. Instruct to assess pulse daily before arising and
notify the physician if 5 or more BPM slower than the preset pacemaker rate.
 Incision care and signs of infection. Bruising may be present following surgery.
 Signs of pacemaker malfunction to report, including dizziness, fainting,
fatigue,weakness, chest pain, or palpitations.
 Activity restrictions as ordered.This usually is limited to contact sports (which may
damage the generator) and avoiding heavy lifting for 2 months after surgery.
 Resume sexual activity as recommended by the physician. Avoid positions that cause
pressure on the site.
 Avoid tight-fitting clothing over the pacemaker site to reduce irritation and avoid skin
breakdown.
 Carry the pacemaker identification card at all times,and wear a MedicAlert bracelet or
tag.
 Notify all care providers of the pacemaker.
 Do not hold or use certain electrical devices over the pacemaker site, including
household appliances or tools, garage door openers, antitheft devices, or burglar
alarms. Pacemakers will set off airport security detectors; notify security officials of
its presence.
 Avoid strong magnetic forces such as those from MRI machine. Inform the doctor of
implanted pacemaker before undergoing MRI
 Keep all scheduled doctor’s appointments.

COMPLICATIONS

Pneumothorax: This occurs in approximately 1 in 100 patients. The veins used to get the
pacemaker wires to the heart lie very near to the lung. It is possible to nick the lung on
the way past causing an air leak. Sometimes this resolves on its own. Occasionally a
chest drain is needed.

Pericardial effusion: This occurs in approximately 1 in 500 patients. When the wire is
positioned in the heart it can cause a fluid collection around the outside of the heart.
Sometimes this resolves on its own but occasionally a drain is needed; very rarely an
operation is needed.

Infection: this occurs in approximately 2 in 100 patients. Antibiotics are given routinely
to help prevent this. In the unlikely event that the pacemaker does become infected, it
will probably need to be removed and a new pacemaker implanted.

Haematoma: This occurs in approximately 4 in 100 patients. Rarely this bruising may
need drainage.  Patients taking blood thinning drugs are more prone to haematoma
formation.

Wire displacement: This occurs in approximately 2 in 100 patients. This causes the
pacemaker to pace inappropriately.  In most cases the wires need to be repositioned
requiring further surgery.

Death: This is fortunately an extremely rare complication

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Normal aging of the heart may disrupt our heart rate, making it beat too slowly.
Heart muscle damage resulting from a heart attack is another common cause of
disruptions of our heartbeat. Some medications can affect our heart rate as well. For
some, genetic conditions cause an abnormal heart rate. Regardless of the underlying
cause of an abnormal heart rate, a pacemaker may fix it.