Pacemakers 12/04

1-What is a pacemaker?
2- What does intrinsic mean?
3- How exactly do pacemakers work on the heart?
4- What are the parts of a pacemaker?
5- re there different kinds of pacemakers?
!- What is the ad"anta#e of two wires o"er one?
$- How are pacemakers inserted?
%- What do they mean &y trans"eno's( transc'taneo's( and transthoracic?
)- How does the #enerator &ox work?
1*- How lon# do the implanted &atteries last?
11- How m'ch electricity does the pacemaker 'se to act'ally pace the heart?
12- +n ,n#lish( please?
13- What is capt're threshold?
14- Why do paced &eats #enerated &y a "entric'lar wire look like -./s?
15- What does asynchrono's mean( and what does demand mean?
1!- What do those letters0 ..+( 111( etc2 stand for?
1$- What is fail're to capt're?
1%- What is fail're to sense?
1)- How can an implanted pacemaker &e repro#rammed?
2*- What is the ma#net thin#?
21- What are some reasons for placin# a permanent pacemaker?
22- What is an +/1?
23- /an +/13s also f'nction as pacemakers?
24- What pro&lems do +/13s ha"e?
25- How do yo' stop an +/1 from shockin# the patient incorrectly?
2!- /an yo' shock a patient with a pacemaker?
2$- What is external cardiac pacin#?
2%- Who was 4oll( anyhow?
2)- What else do + need to know a&o't r'nnin# the external pacemaker?
3*- How do + know if capt're has &een achie"ed?
31- What3s the tricky part?
32- 1oes external pacin# h'rt?
33- How lon# can a person stay on the external pacemaker?
34- How does the 4oll #o into demand mode?
35- ny other 4oll tricks?
3!- /an yo' do /-5 with the external pacer in place?
3$- How effecti"e is the 4oll?
Pacemakers
1. What is a pacemaker?
pacemaker is an electronic de"ice that pro"ides an electrical si#nal to make the heart &eat
when it3s own( &'ilt-in pacemakers fail2 6he anatomical( &'ilt-in pacemakers pro"ide what3s
called the intrinsic rhythm( and they can &e disr'pted &y "ario's conditions 7 ischemia for
example( or &y an 8+2
2. What does intrinsic mean?
+ntrinsic means &'ilt in2 +n this sit'ation( it means0 comin# from the patient3s own &'ilt-in(
nat'ral pacemakers 0 the 9 or . nodes: or sometimes from lower down in the "entricles2
3. How exactl do pacemakers work on the heart?
6he pacemaker essentially does two thin#s 0 it senses the patient3s own rhythm 'sin# a
sensin# circ'it( and it sends o't electrical si#nals 'sin# an o'tp't circ'it2 +f the patient3s
intrinsic rhythm &ecomes too slow or #oes away completely( the electronic pacemaker senses
that( and starts sendin# o't si#nals alon# the wires leadin# from the control &ox to the heart
m'scle2 6he si#nals( if they3re capt'rin# properly( pro"ide a re#'lar electrical stim'l's(
makin# the heart contract at a rate fast eno'#h to maintain the patient3s &lood press're2
Here3s the &ox( implanted2
How many pacin# wires?
http0;;www2&orleyrectory2com;myessays;pacemaker2htm
4. What are the parts o! a pacemaker?
6he pacemaker &ox itself is called the p'lse #enerator 7 the #enerator is connected to
either one or two wires( which carry the electrical si#nals to the heart m'scle2 -ermanent
pacin# #enerators are implanted in the chest 'nder the skin 7 nowadays they3re "ery small 7
and the wires leadin# to the heart are threaded thro'#h the s'&cla"ian "ein2
2
". #re there di!!erent kinds o! pacemakers?
-acemakers can &e either temporary or permanent2 6he
temporary pacemakers that we see in the 8+/< are
made 'p of a control &ox and one sin#le o'tp't wire
leadin# to the inner wall of the 5. =th's called a
"entric'lar wire( or .-wire>( and pro"ide simple rate
control &y pacin# the "entricles2 -ermanent pacemakers
come in se"eral fla"ors( &'t the main difference &etween
them is that some ha"e only one wire leadin# to the 5.(
and some ha"e two 7 one to the ri#ht atri'm =5>( and
another one to the 5.2 pacin# system that paces &oth
the 5 and the 5. is called an atrio"entric'lar pacer(
and paces &oth ri#ht heart cham&ers in se?'ence2 6he
si#nal affects the left-side cham&ers and stim'lates them
to contract as well2 6he si#nal from the wire #enerates a
"is'al si#nal on the ,@A that looks like( and is called a
spike2
Here3s an example of a temporary( external( sin#le-wire
pacin# &ox2 6he wire has two pole connections( so one pair of
connectors0 sin#le wire &ox2
http0;;www2pacemedicalinc2com;45432htm
Here3s a nice example of sin#le-wire pacin#( with spikes comin# at a rate in the $*3s2 6he
reason we can tell that there3s only one wire #oin# is simply that there3s only one spike2 6wo-
wire systems #enerate two spikes2
How many spikes this time?
3
,"ery&ody see the two spikes?
6he arrows aren3t perfect 7 &'t
clearly there are two pacin#
f'nctions #oin# on here0 the first
spike is #eneratin# atrial kick( and
the second is kickin# the
"entricles0 two spikes( two wires2
6hese spikes #o &oth 'p
and down in front of the
B593s( which yo' see
sometimes 7 a normal
"ariant2
6wo sets of connectors0 two wires2 9o what kind of &ox is this?
http0;;www2oscor2com;defa'lt2asp?owc;tempC2*pacin#2aspDmain
$. What is the ad%anta&e o! two wires o%er one?
+f yo' pace the "entricle alone( the patient doesn3t #et the atrial kick 7 the p'sh of the atria
into the "entricles2 6his can act'ally add 2*-25C to the cardiac o'tp't( and impro"e the
&lood press're accordin#ly2 nice example of this was a patient we saw recently who had a
temporary .-wire in place2 When she was paced at a rate of $*( she only #ot a &lood
press're of a&o't %5( systolic2 E't when the pacer rate was t'rned down( her intrinsic rate
took o"er at a&o't a rate of !* 7 sin's rhythm( which meant that she started #ettin# her atrial
kick a#ain 7 and her &lood press're rose( e"en with the slower rate( to a&o't 1*52 lso a nice
example of how the fastest rate will capt're0 first the wire( then the intrinsic one2
$. How are pacemakers inserted?
temporary pacin# wire is threaded thro'#h an introd'cer placed in a central line site(
's'ally the ri#ht internal F'#'lar or s'&cla"ian2 =6he ri#ht +G is the strai#htest shot down into
the 5.( which is where yo' want yo'r temporary wire to #o2> Howadays we rarely 'se
trans"eno's wire insertion at the &edside 7 we apply the transc'taneo's pacer( or 4oll
instead2 Ince in a #reat while a transthoracic wire placement is attempted( 's'ally at the end
of a code when nothin# else is workin#J
'. What do the mean ( trans%eno)s* transc)taneo)s* and transthoracic?
6rans"eno's means that the pacin# wire is threaded down the F'#'lar "ein thro'#h an
introd'cer =the same as a - line introd'cer>2 6he introd'cer is p't in first( like any central
neck +. line( and the wire is passed thro'#h it( like a - line is( 'ntil it makes contact with the
inner wall of the 5.2 6hen the wire is attached to a #enerator &ox( and the heart is paced
'sin# the wire2 We hardly e"er do this at the &edside anymore( since the comin# of the 4oll
external pacer2
4
6ransc'taneo's pacin# means 'sin# external pacin# pads connected to a de"ice like the 4oll
machine( or one of the defi&rillators that has external pacin# a&ility2
6ransthoracic pacin# means 'sin# wires inserted either d'rin# cardiac s'r#ery 7 small wires
that sit on the o'ter wall of the heart 7 epicardial wires( that lead o't of the chest( to a
control &ox - or doin# a mane'"er that in"ol"es p'shin# a pacin# wire into the 5. 'p thro'#h
the chest wall( s'&xiphoid( d'rin# a code2 +3"e only e"er seen this tried once and it didn3t
work2 ccordin# to a we& so'rce that we looked at( the proced're isn3t "ery pop'lar( can
create a whole slew of nasty complications( and 's'ally isn3t any 'se anyhow2
+. How does the &enerator (ox work?
6he #enerator &ox consists of a small comp'teriKed chip controller that3s r'n &y a &attery2
6he &ox senses and paces thro'#h the same set of wires that lead to the endocardi'm2
,. How lon& does the (atter last?
s + 'nderstand it( implanta&le pacers 'se lithi'm &atteries that last anywhere from ! to 1*
years2 6he &attery in a temporary pacin# &ox is a re#'lar hardware-store type )-"olt &attery2
10. How m)ch electricit does the pacemaker )se to act)all pace the heart?
6he o'tp't of the pacemaker is meas'red in two ways0 si#nal amplit'de( and p'lse width2
11. -n .n&lish* please?
9i#nal amplit'de means how m'ch F'ice the &ox p'ts o't thro'#h the wire with e"ery p'lse2
6his is meas'red in milliamperes( and is called 8 7 there3s a twisty dial to control the 8 on
the front of the temporary pacer &ox2 -'lse width means how lon# each p'lse lasts2 6he
electrical p'lse has to &e stron# eno'#h( and last lon# eno'#h( to capt're the myocardi'm2
12. What is capt)re threshold?
/apt're threshold is the minim'm amo'nt of electricity that the &ox has to emit to pace the
heart 7 as a&o"e( it3s meas'red in milliamps( and the twisty kno& is t'rned 'p 'ntil the heart is
paced 1**C - then t'rned down a#ain 'ntil the minim'm is determined2
13. Wh do paced (eats &enerated ( a %entric)lar wire look like P/0s?
6he reason that -./s look wide and &iKarre is &eca'se they ori#inate down at the &ottom
of the heart( at the opposite end from where they 's'ally come - the path of depolariKation is
&ackwards as a res'lt2 6hink of the normal lead ++ si#nal( #oin# from northwest to so'theast0
Ire#on to Llorida2 paced si#nal is #oin# &ackwards( 'pwards =retro#rade> - the re"erse
of the normal B59 wa"eform2 9ince the "-wire #enerates a rhythm &y emittin# electricity from
a wire whose tip is em&edded in the wall of the 5.( the deflection follows the same path as a
-./ 7 so it looks like one2
5
Here3s the two-wire pacin# strip a#ain0 one wire is in the ri#ht atri'm( and the other3s in the
ri#ht "entricle2 With two wires( the "entric'lar path is still &ackwards( F'st as with one 7 makes
sense( ri#ht?
14. What does asnchrono)s mean* and what does demand mean?
temporary control &ox can &et set to r'n - F'st r'n - at a fixed rate( i#norin# any si#nals that
the patient3s heart may &e makin# =asynchrono's>: or it can &e set to pace only if the intrinsic
heart rate #ets too slow =pacin# on demand>2 Heedless to say( yo' wo'ld 'se the first way
of pacin# only if the patient3s heart rate was either m'ch too slow( as may happen if the
patient wipes o't some of her cond'ction system &y infarct( or if the rhythm F'st isn3t there( as
in asystole( may&e for the same reason2 6here3s a second twisty dial that controls how
sensiti"e the &ox will &e to the patient 7 for f'll control( yo' wo'ld t'rn it all the way 'ntil the
control kno&3s arrow pointer was all the way towards the word asynchrono's2 +nsensiti"e2
6ake the pacin# #enerator o't of the emer#ency pacin# tackle &ox a few times( and #et
familiar with it2
Here3s the strip we looked at on pa#e 32 6his is fixed-rate pacin#2 Hot necessarily
asynchrono's( &'t this is what it wo'ld look like0
6his same dial can also &e t'rned in the other direction( away from asynchrono's 7 this
increases the sensiti"ity of the &ox( so that it will start sensin# the patient3s own rate2 +f yo'
want the &ox to start pacin# the patient only when the intrinsic rate #ets too slow 7 on
demand( then yo' adF'st the sensiti"ity of the &ox so that it can see the patient3s rhythm2
6his will inhi&it the &ox from firin# when it sees intrinsic &eats2 6he cardiolo#y people are
's'ally responsi&le for these settin#s( &'t the idea is pretty simple0 it3s &etter if the patient3s
own rhythm controls the heart( especially if all yo' ha"e is a .-wire =no atrial kick with only a
"-wire( remem&er> 7 &'t if it slows down &elow a certain point( the &ox will wake 'p and take
o"er2 6he intrinsic rhythm stops or slows( and the inter"al is lon# eno'#h for the pacer to t'rn
on2
5emem&er that the wire has to #enerate a rate that3s fast eno'#h to make an ade?'ate &lood
press're2 +f the demand rate is set so that the &ox only kicks in at a rate of !*( that may not
&e eno'#h( especially if yo'3re only workin# with the one wire2
6
1". What do those letters1 //-* 222* etc.* stand !or?
We really only see two kinds of pacemakers in the 8+/< 7 sin#le "-wire pacin# ='s'ally
temporary wires placed for &radycardias and the like>( and permanently implanted -.
pacers2 9in#le "-wire systems are called ..+ pacers( and the -. pacers are called 1112
6he first letter stands for the cham&er that is paced( the second letter is for the cham&er that
is sensed( and the third letter stands for the response the pacer makes to a sensed intrinsic
&eat2 9o a ..+-mode pacer paces the 5.( senses the 5.( and is +nhi&ited from firin# if it
senses an intrinsic &eat2 111 pacers pace &oth cham&ers =1 stands for d'al>( they sense
&oth cham&ers( and each of the two wires is inhi&ited &y an intrinsic &eat2
6his can prod'ce a "ery cool res'lt0 a patient may #enerate her own --wa"es( &'t fail to
cond'ct them 7 may&e she has a fritKed-o't . node2 6he -wire will &e inhi&ited &y the
patient3s -3s( &'t the "-wire will sense( and follow them2 9o the patient will &e in a sin's
rhythm( with "-pacin#( and will &e a&le to increase and decrease heart rate in a normal way
in response to exercise( and the like2 ,xcellentM
1$. What is !ail)re to capt)re?
Here the idea is that the pacin# &ox sends an imp'lse to the heart at the ri#ht time( &'t the
heart doesn3t respond2 6he &ox is sensin# that the intrinsic heart rate is too slow( &'t the
o'tp't si#nal isn3t makin# the myocardi'm respond2 No' see this on a rhythm strip when there
are clear pacin# spikes comin# from the &ox 7 at the ri#ht time after either an intrinsic &eat or
a paced one 7 &'t they3re not followed &y a B59 response2 6here can &e all sorts of reasons
for this0 &roken wires( pacemaker &ox fail're( acidosis( alkalosis( &ad connection to an
external pacin# &ox( &attery fail're( the moon in .ir#oJ this can &e serio's if the patient is
dependin# on the pacemaker to maintain a &lood press're2 .ario's mane'"ers can &e made
with the pacer control &ox to re-esta&lish proper capt're 7 the ?'ickest one is 's'ally to t'rn
'p the 8 o'tp't2 /all the team2 While yo'3re waitin#( ha"e atropine at the &edside( and the
4oll near&y in case &ad capt're #oes to no capt'reM
/opyri#ht 2***( 8ad 9cientist 9oftware( www2madsci2com;man';ek#Orhy2htm
6he point to remem&er0 the pacer spikes are comin# at the ri&ht time relati"e to the patients
rate( or lack of a rate 7 &'t they3re not capt'rin#2
7
Where3s the B59?
1'. What is !ail)re to sense?
5emem&er( the pacemaker has &oth a sensin# circ'it and an o'tp't( or pacin# circ'it2 6he
pacer has to sense whether or not the patient is #eneratin# a rhythm( so it will know when to
pace and when not to2 +n this case the pacemaker will #enerate spikes that do capt're( &'t
the spikes come at the wron# time( and the &ox is clearly 'na&le to see what the patient3s
heart is doin#2 /learly a &ad thin# 7 it can res'lt in the infamo's 5-on-6 sit'ation( prod'cin#
.6 or .L2
6he thin# to keep in mind0 the pacer spikes will &e comin# at the wron& time2 6his may F'st
&e an improper sensiti"ity settin# on the &ox2
www2 monroecc22ed';depts;pstc;paracar52htm
1+. How can an implanted pacemaker (e repro&rammed?
6here3s a machine that the physician 'ses to comm'nicate with an implanted pacemaker2
1,. What is the ma&net thin&?
No'3"e pro&a&ly seen the physicians do this mysterio's mane'"er with a rin#-shaped ma#net
that #ets placed on the patients3 chest o"er the pacemaker2 6he idea here is that there is a
switch inside the pacemaker with a ferro's reed( which is p'lled from one position to the
other &y the ma#net2 6his is in"ol"ed in fi#'rin# o't how m'ch lon#er the pacers3 &attery has
to li"e( and also chan#es the pacemaker into f'lly asynchrono's mode for testin# p'rposes2
20. What are some reasons !or placin& a permanent pacemaker?
6here are lots of thin#s that an 'nhappy heart can come 'p with that will indicate the need for
a pacemaker0 sick-sin's and tachy-&rady syndromes will do it( certainly rec'rrent
8
Here we are failin# to sense2 =+t3s
's'ally a #'y thin#J> 6he spikes
are certainly re#'lar( &'t are they
comin# at the ri#ht time( relati"e to
the patient? Ho 7 the &ox isn3t
seein# the patient3s rhythm( and it3s
firin# off &lindly2 =6hree doctors #o
d'ck h'ntin#J>
&radycardias that drop the E- will do it( heart &locks =especially which one?> 7 yo' #et the
idea2 +f the heart isn3t #eneratin# a rate for whate"er reason( pacin# will pro&a&ly &e needed2
21. What is an #-02?
+/1 stands for 'tomatic( +mplanta&le( /ardio"erter-1efi&rillator2 6his is a "ariation on the
idea of a pacemaker 7 the de"ice has a sensin# circ'it and an o'tp't circ'it( &'t instead of
actin# as a pacer( it spends it3s time waitin# for the onset of some nasty tachyarrhythmia( like
.6( or 9.6 7 which it then tries to shock the patient o't of2 pparently they will also
sometimes try to o"erride-pace a patient o't of a rapid rhythm2
22. 0an #-02s also !)nction as pacers?
pparently the newest #eneration of +/1s can do &oth2

23. What pro(lems do #-02s ha%e?
/learly yo' wo'ldn3t want to &e defi&rillated at the wron# time2 + ha"e no idea how common a
pro&lem this is 7 + ha"e heard of it happenin#( and of patients ha"in# to come in and ha"e the
&ox repro#rammed( or sh't off2 9imilarly to pacemakers( +/1s can fail to sense( or to
capt'reJ
24. How do o) stop an #-02 !rom shockin& the patient incorrectl?
pparently the rin# ma#net will sh't off the cardio"erter( &'t will allow the pacer f'nction to
keep #oin# if necessary2 We need to check into thisJ

2". 0an o) shock a patient with a pacemaker?
6he last time this came 'p in the 8+/<( we called the //<( and they told 's that it3s
#enerally safe to shock a patient with an implanted pacemaker2
2$. What is external pacin&?
6ransc'taneo's pacin# is the 'se of the 4oll machine( or its e?'i"alent2 ,xternal pacin#
capa&ility is &'ilt into the defi&rillators that we 'se in the 'nit2 Par#e sticky pads are applied to
the patient3s chest and &ack =it3s important to check the placement dia#ram on the pad
packa#e>( and connected to the 4oll o'tp't ca&le2 6he ca&le deli"ers electricity to the pads(
hopef'lly capt'rin# and pacin# a heart that3s too slow2
6here3s &een an important chan#e in the
way the pads are applied0
Here3s the way we 'sed to do it2 6hese
pads are in the same position 'sed for
cardio"ersion( defi&rillation( those
thin#sJ
9
Here3s the way we do it now2 6he idea is
sort of to sandwich the heart
&etween the pads2 pparently works
m'ch more &etter2
6his really is important0 take the time to #o
o"er this st'ff &efore yo' need to do in emer#ently2 Ara& the reso'rce n'rse( or a senior
staff person( or another new&ie( and take a #ood look at how the parts of the e?'ipment fit
to#ether( how they work( where replacments are keptJ
2'. Who was 3oll* anhow?
1r2 4oll was apparently the medical researcher who did the ori#inal
research and de"elopment of transc'taneo's pacin#( and who
patented the machine in the early 1)%*3s2
http0;;Koll-aed2com;dr-Koll2Fp#
2+. What else do - need to know a(o)t r)nnin& the external pacer?
I'r machine has only three controls that yo' ha"e to worry a&o't0 one chan#es the &ox from
monitor mode to pacin# mode( and the other two are the pacer control kno&s2
6he &asics are really not hard2 5emem&er that the external pacin# &ox sho'ld &e a&le to see
the patient( as well as pace the patient( so there is a sensin# ca&le that attaches to three
chest electrodes2 No' can pace the patient witho't this( so in an emer#ency F'st #et the pads
on and #o - &'t ha"in# the a&ility to sense is &etter2
6he pacin# electrodes are the &i# white sticky thin#s 7 one #oes on the front of the chest( one
#oes on the patient3s &ack 7 a#ain( check the positionin# dia#ram on the packa#e that they
come in2 6hese connect to the ca&le that lets the &ox pace the patient0 an o'tp't ca&le
comin# from the &ox2
2,. How do - know i! capt)re has (een achie%ed?
6his is a &it tricky( &'t o&"io'sly important2 +f there3s time( make s're that the 4oll3s sensin#
ca&le is attached to the patient 7 3 electrodes in a standard lead ++ pattern( &eca'se it helps if
the machine can see the patient3s heart rate2
10
How the kno&s - start with &oth kno& controls0 rate( and power =8> o'tp't - set at Kero2 6'rn
the heart rate kno& 'p to a rate that yo'3d like to pace the patient at 7 this is pretty simple0 if
the patient3s rate is 2*( pick somethin# like !* - %* &eats per min'te2 How start t'rnin# 'p the
power o'tp't kno& 7 it sometimes takes a lot of power to capt're 7 somethin# like 1** to 15*
82
30. What4s the trick part?
Here3s the tricky part2 +f yo' look at the patient3s monitor for e"idence of capt're( yo' may &e
fooled2 6he electrical acti"ity of the external pacer shows 'p clearly on the monitor as lar#e
f'nny-lookin#-&eats( and they will occ'r at whate"er rate of &pm that yo' chose2 6he
appearance of these &eats does not mean that the patient3s heart has &een capt'redM No'
need to act'ally ha"e some way to tell that the heart is &ein# paced - and #eneratin# &lood
press're - at the rate yo'3re tryin# to pace them at2 9o if the patient has an a-line( try lookin#
at the wa"eform heart rate co'nter to match yo'r desired rate( or the p'lse oximeter heart
rate co'nter 7 or feel the patient3s p'lse( which may &e hard to do if they3re hypotensi"e2 9ee
if the patient3s &lood press're is respondin#2 1on3t ass'me that the electrical acti"ity of the
pacer means that the heart is &ein# pacedM
31. 2oes external pacin& h)rt?
Nes( dependin# on how m'ch F'ice they #et( &'t also dependin# on how &i# the external
pacin# pad is2 +t seems that the lar#er electrode siKe does away with most of the pain
in"ol"ed2 + hope so - it doesn3t look "ery comforta&leJ
32. How lon& can a person sta on the external pacemaker?
-ro&a&ly not too lon#2 +n my experience( an ho'r or two if the patient really needs a wire2
6he whole point of the de"ice is to pro"ide temporary pacin# in a critical sit'ation 'ntil the
patient can #et a wire inserted in the cath la&2 6his has almost completely replaced the
placement of trans"eno's pacin# wires in code sit'ations( altho'#h sometimes it3s still tried2
6he external pacer may stay on in demand mode in a patient who doesn3t need a wire( &'t
whose rate only rarely #oes too low 7 may&e while waitin# for a di#oxin le"el to come down2
=Pook 'p di#i-&ind>2 6his is a medical F'd#ment call2
33. How does the 3oll &o into demand mode?
Ince yo'3"e determined that the 8 is set hi#h eno'#h to capt're 1**C =all the time(
relia&ly>( try t'rnin# down the rate kno& to let the patient3s own heart rate take o"er =ass'min#
they ha"e a rate at allM> 7 if they do( and if that #enerates an ade?'ate &lood press're( the
4oll3s rate can &e left at a n'm&er low eno'#h not to interfere with the patient3s intrinsic rate
'nless it drops too far 7 at which point the 4oll will kick in on demand2 6he 4oll will also r'n
&lind( that is( witho't the sensin# ca&le attached0 if yo'3re in a real h'rry( say( in an asystolic
code( yo' can F'st slap on the pads( pick a rate( t'rn the 8 'p to max( and #o2 ,sta&lish
capt're first( and try to find the capt're threshold laterJ
34. #n other 3oll tricks?
'sef'l one is0 if yo' ha"e time( &enKoin the skin 'nder the o'ter part of the pacin# pads 7
not on the #el part 7 &eca'se people tend to sweat the pads off2 1an#ero's2 ?'ick
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additional point a&o't this0 if yo' sho'ld come across sticky defi&rillation pads( which are
'sed for patients that re?'ire repeated shocks =+3"e only e"er seen them once here in the
8+/<>( don3t &enKoin them on 7 it can ca'se arcin#M
3". 0an o) do 0P5 with the external pacer in place?
6he literat're +3"e read says yes 7 &'t that yo' sho'ld t'rn the pacin# &ox off2 =1'h2>
3$. How e!!ecti%e is the 3oll?
pparently pretty effecti"e - the s'r"i"al rates are reported as ran#in# from 5*-1**C2 6he
secret0 #et it 'p and r'nnin# promptly2 1id yo'r patient F'st need a dose of atropine? -'t the
pads on( ri#ht now( and #et the ca&les and &ox hooked 'p( ready to r'n2 ny time wasted(
any time the patient spends hypotensi"e or &ecomin# e"en moderately acidotic increases the
chance that the de"ice won3t work2 nd #et a call in to the cath la& at the same timeJ
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