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PACEMAKER INSERTION BY TRANSVENOUS ROUTE (TVPM)
- Every PM has:
- pulse generator that contains battery (life span 5-15 years) and circuit to analyze rhythm
- leads that sense and stimulate the myocardium. These leads can be unipolar or bipolar that on EKG are distinguished by size of spikes (high in unipolar).
Indications for TVPM in ER are discussed in detail in "Cardiology" chapter
Most common reasons for PM are symptomatic bradycardia, AVB, asystole and MI associated with certain conduction defects.
Procedure can be performed assisted or unassisted by EKG monitor (unassisted in case of asystole).
Any of the veins described for central line placement can be used to place TVPM, but it is preferable to use R IJ (goes directly into SVC) or L Subclavian (the anatomy of L subclavian accommodates the
design of central line catheter to proceed easier into SVC). Cases where femoral approach is used, TVPM kit must contain 1 M long (100 cm) catheter.
Prep the area you will be cannulating as described in "Central Line" section. Place on telemetry monitor.
Open TVPM kit and Cordis catheter.
Once Cordis is inserted, start to thread the PM electrode through it. Lead V1 must be attached to the electrode.
Once electrode is in the R atrium it will show a negative P wave. Inflate the balloon and continue to thread catheter.
Once you are in R ventricle you will see wide complex LBBB-type QRS on V1 (QRS is downward) . Deflate the balloon. If RBBB instead of LBBB is observed (positive QRS on V1), you are in Pulmonary artery or a septal
perforation has occurred and you are in L ventricle (not a common complication).
Advance 2-3 inches until you see ST elevations. You create a "cardiac injury" by touching probe to endocardium.
Attach the external end of electrode to the pulse generator . Dial the generator to the targeted HR and begin pacing. PM spikes should appear on monitor.
Confirm placement by CXR.
**Complications include perforation, pericarditis, arrhythmias
(mainly ventricular, such as VT and VF). |
