Emergency Management of Pacemaker Failure

The purpose of this report is to describe the more common problems encountered with permanent pacemakers and their management. One of the serious recurring problems is loss of output from the pacemaker. As a result, no pacemaker impulse whatsoever is seen on the electrocardiogram and the heart rate appears slower than the fixed rate of the pacemaker. In such a situation, if a patient is pacemaker dependent, whereby he will become symptomatic without the pacemaker, a temporary pacemaker electrode must be inserted immediately as an emergency procedure. On the other hand, if the patient can get along for a while without the pacemaker, then the pulse generator can be replaced electively under local anesthesia. In taking care of any patient, it is extremely important to decide whether or not the patient is pacemaker dependent. This information must be readily available; thus, by providing the patient with some type of identification bracelet or by labeling the chart with a specific tag, the patient will be treated appropriately and without delay. Another problem that appears frequently is change of pacemaker rate. The most common cause for a change in rate is the drop in output of the battery. This can usually be determined by the exclusion of two other possibilities: competition and change in impedance. If the patient is "competing," the pulse at the wrist may be considerably slower than the rate seen on the electrocardiogram. An electrocardiogram will demonstrate whether or not the pacemaker is behaving normally, and if the pulse deficit is a result of an inability to palpate early coupled beats. A change in the impedance of the electrode, as seen when the tip of an electrode breaks, can also change the pacemaker rate if that