Sammanfattning:

  • ABC.
  • Koppla upp patient till monitor.
  • Lägg till plattor fram och bak.
  • Aktivera PACING knappen, börja på 70 frekvens – 70 mA!

Bakgrund:

I linje med akutsjukvårdens grundprinciper: om hjärtats elektriska system inte genererar impulser, så får vi generera dem externt.

Vid symtomgivande bradykardi kan extern pacing vara en brygga till intravaskulär pacemaker.

Om Atropin 0,5 mg ej har effekt, om kronotropi med sympatikomimetika eller Isoprenalin inte har effekt och om patientten är tydligt symtomatisk av sin bradykardi övervägs extern pacing. Det lär vara så att en hjärtbank generar runt 1 J, och kan ge ett pulsgivande slag.
Extern paceing via defibrillator skall övervägas vid allvarliga symtom. Det är smärtsamt, får ej försiggå längre än 8 timmar, och kräver i regel (lätt) sedering.

Om patienten är okontaktbar utan egen andning och bradykard, så startas HLR.

Bradykardi är isolerat inte en indikation för extern paceing, en patient kan vara uppegående på frekvens på 25. En lätt yrsel som går över när man lägger sig är inte heller indikation. Så först: ABC som vanligt.

Indikation:

  • Symtomgivande bradykardi
  • Medvetandepåverkad: >=2 i RLS
  • Ingen effekt av Atropin 0,5 mg iv
  • Enligt ESC skall kronotropa droger intravenöst prövas först. (Dvs Isoprenalininfusion, eller krono/inotropi med Adrenalin)

Praktiskt tillvägagångssätt

  • Var beredd med sedering / analgesi. (tex Ketamin och lågdos Midazolam)
  • Applicera både elektroder och defibrillerings/pacing-plattor. När man slår om till paceing kan plattorna inte avläsa längre. Plattor sätts på i antero-posterior position.
  • Innan pacing startas bekräfta att det detekteras QRS (via elektroderna)
  • Pacing-frekvens minst 10-20 slag högre än patientens egenrytm
    Normalt frekvens 60-70 slag/min
  • Strömstyrkan: starta så lågt det går, höj tills man uppnår effektiv pacing (capture), dvs man ser spikes på monitoringen. Notera tröskelvärdet.
    Vanligen 40-80 mA, stimulering bör ske med ca. 10% över tröskelvärdet. (ca 5-10 mAmp över tröskelvärdet.) Om ingen effekt av 120-130mA, så bör man kontrollera elektroder och plattor.
  • Kontrollera att patientens perifera pulsar motsvarar inställd frekvens

Referensmaterial:

Skånes PM om extern pacing

SU/S rutin för extern pacemaker efter hjärtkirurgi

European Society of Cardiology:

ESCs guidelines on cardiac pacing från 2021 finns ett kortfattat stycke, som läggs med här eftersom det är väldigt långa dokument:

11.3 Temporary pacing / ur ESC guidelines om cardiac pacing, 2021

Temporary pacing can provide electronic cardiac stimulation in patients with acute life-threatening bradycardia or can be placed prophylactically when the need for pacing is anticipated (e.g. after cardiac surgery).764,765 Modalities for emergency temporary pacing include transvenous, epicardial, and transcutaneous approaches. The transvenous approach often requires fluoroscopic guidance, although echo-guided placement is also feasible.766 Balloon-tipped floating catheters are easier to insert, more stable, and safer than semi-rigid catheters.767,768 Patients who undergo transvenous temporary cardiac pacing have a high risk for procedure-related complications (e.g. cardiac perforation, bleeding, malfunction, arrhythmias, and accidental electrode displacement) and complications related to immobilization (e.g. infection, delirium, and thrombotic events).764,765,769–775 In addition, previous temporary pacing is associated with an increased risk of permanent pacemaker infection.639,641 A percutaneous transvenous active fixation lead connected to an external device is safer and more comfortable for patients requiring prolonged temporary pacing.776–779 There are no good data that support either a jugular or axillar/subclavian access; however, intrathoracic subclavian puncture should be avoided to reduce the risk of pneumothorax. A jugular access should be preferred if implantation of a permanent ipsilateral device is planned. In selected cases where fast and efficient pacing is needed, a femoral access may be used. Owing to instability of passive leads placed through the femoral vein and immobilization of the patient, the duration of this approach should be as short as possible until bradycardia has resolved or a more permanent solution has been established. The epicardial approach is mostly used following cardiac surgery. Removal of these leads is associated with complications such as bleeding and tamponade.780–782 Transcutaneous temporary pacing is a fast and effective non-invasive method, but is not as stable as the transvenous approach, and is limited by the need for continuous sedation.783 This modality should only be used in emergency settings or when no other option is available, and under close haemodynamic monitoring.784 Before starting temporary pacing, chronotropic medication should be considered, taking into account side effects, contraindications, and interactions with other medication.

This Task Force concludes that temporary transvenous pacing should be avoided if possible; when it is required, the lead should remain in situ for as short a time as possible. The use of temporary pacing should be limited to the emergency treatment of patients with severe bradyarrhythmia causing syncope and/or haemodynamic compromise, and to cases in whom those bradyarrhythmias are anticipated. Temporary transvenous pacing is recommended when pacing indications are reversible, such as in the context of antiarrhythmic drug use, myocardial ischaemia, myocarditis, electrolyte disturbances, toxic exposure, after cardiac surgery, or as a bridge to permanent pacemaker implantation when this procedure is not immediately available or possible due to concomitant infection. Lastly, if a patient meets the permanent pacemaker implantation criteria, this procedure should be performed promptly.

Ur ERC s riktlinjer om HLR och periarrest -rytmer, bradyarytmi:

If bradycardia is accompanied by adverse signs, give atropine
500mg IV (IO) and, if necessary, repeat every 35 min to a total of
3 mg.
If treatment with atropine is ineffective, consider second line drugs.
These include isoprenaline (5 mikrogram / minut som startdos) and
adrenaline (2-10 mikrogram / minut som startdos).
For bradycardia caused by inferior myocardial infarction, cardiac
transplant or spinal cord injury, consider giving aminophylline
(100- 200 mg slow intravenous injection).
Consider giving glucagon if beta-blockers or calcium channel
blockers are a potential cause of the bradycardia.
Do not give atropine to patients with cardiac transplants  it can
cause a high-degree AV block or even sinus arrest  use
aminophylline.
Consider pacing in patients who are unstable, with symptomatic
bradycardia refractory to drug therapies.
If transthoracic pacing is ineffective, consider transvenous pacing.

Whenever a diagnosis of asystole is made, check the ECG
carefully forthe presence ofP waves because unlike true asystole,
this is more likely to respond to cardiac pacing.
If atropine is ineffective and transcutaneous pacing is not
immediately available, fist pacing can be attempted while waiting
for pacing equipment.