Vagal maneuver
techniques used to increase vagal parasympathetic tone in an
attempt to diagnose and treat various arrhythmias.
Common vagal maneuvers include carotid sinus massage
(CSM), Valsalva maneuver (VM), and diving reflex.
transiently increase the arterial pressure in the carotid sinuses
and aortic arch. This action triggers the baroreceptor reflex,
which results in increased parasympathetic output to the heart
via the vagus nerve (cranial nerve X).
location of the carotid sinus is at the bifurcation of the internal
and external carotid artery from the common carotid artery.
The sinus contains baroceptors that sense changes in blood
pressure.
Within the aortic arch, there are baroreceptors that sense
changes in aortic arterial pressure. These receptors send
afferent signals to the NTS via the vagus nerve.
The result of the increased frequency of afferent signals due to
increased arterial pressure is the stimulation of vagal nuclei in
the medulla. These nuclei send efferent parasympathetic
signals down the right and left vagus nerves to the heart.
Within the heart, the right vagus nerve serves to stimulate the
sinoatrial (SA) node, the pacemaker of the healthy heart, in the
right atrium; this causes slowed electrical activity within the
SA node. The left vagus nerve mostly innervates
atrioventricular (AV) node, which slows conduction between
the atria and the ventricles.
The end product of vagal stimulation is a decrease in the speed
and frequency of electrical impulses in the heart, which could
ultimately slow or terminate a tachydysrhythmia.
Diving Reflex –It gets triggered by breath-holding and cold
water stimulus to the face. The prevailing theory is cold water
exposure triggers the reflex by initiating afferent impulses
from the trigeminal nerve (cranial nerve V), the predominant
sensory nerve of the face. The impulses then stimulate vagal
nuclei in the brain, eventually resulting in the slowing of AV
nodal conduction.
Cardioversion
similar to electrical defibrillation in that a transthoracic
electrical current is applied to the anterior chest to terminate a
life-threatening or unstable tachycardic arrhythmia.
synchronized cardioversion is performed on patients that still
have a pulse but are hemodynamically unstable. It is used to
treat both hemodynamically unstable ventricular and
supraventricular rhythms.
placing a pair of manual paddles on the chest or through the
application of adhesive “hands-free” pads.[5] Most current
defibrillators utilize a biphasic waveform that allows for a
lower energy level to be used to achieve effective cardioversion.
Because of their greater ability to terminate ventricular
dysrhythmias, defibrillators utilizing biphasic waveforms are
preferred to those utilizing the older, monophasic waveform.
The most common cause of sudden cardiac arrest in adults is
pulseless ventricular tachycardia (VT) or ventricular
fibrillation (VF). VT can also occur in the presence of a pulse;
often, it is the precursor to VF. VT is characterized by rapid,
wide (greater than 0.12 seconds) QRS complexes.
Supraventricular Tachycardia (SVT) refers to a cardiac
rhythm greater than 100 beats per minute, which originates
above the bundle of His. SVT is characterized by rapid,
narrow (less than 0.12 seconds wide) QRS complexes.
SVT is usually caused by the repetitive “re-entry“ of the
electrical impulse proximally, instead of propagating distally
through the cardiac conduction system, due to blockages in the
heart’s electrical conduction system.
Any tachycardic rhythm that does not originate in the
ventricles is referred to as SVT. This includes sinus
tachycardia, junctional tachycardia, reentrant tachycardias,
multiple atrial tachycardia (MAT), atrial fibrillation, and atrial
flutter.
During the procedure
To avoid inducing cardiac arrest in a patient with a pulse,
synchronized cardioversion is performed instead of defibrillation
when a patient is in an SVT with a pulse but is considered unstable
according to the definition above. To perform synchronized
cardioversion, the defibrillator is placed into the “synchronize”
mode by pressing the appropriate button on the machine. This
causes the monitor to track the R wave of each QRS complex that
goes by. A synchronizing marker will appear above each QRS
complex, indicating that the synchronize feature is active.
The appropriate energy level is then selected, and the
discharge/shock button is pressed and held. The defibrillator does
not release the shock immediately. Instead, it waits for the next
R-wave to appear and delivers the shock at the time of the R-wave.
This allows the shock to be provided safely away from the T wave,
avoiding the R-on-T phenomenon.
The recommended energy levels used to perform synchronized
cardioversion vary from 50 to 200 joules. Recalling the specific
energy level for a particular sub-type of unstable tachycardia is
difficult, especially in an emergent situation. The safest and easiest
recommendation is to start at the lowest energy level (50 joules),
and if the shock is unsuccessful, double the amount of energy used.
In a refractory case, you will be at 200 joules after just three
shocks.
When a patient is defibrillated, the energy is released through the
paddles or hands-free pads immediately when the defibrillation
button/s are pressed. The shock is delivered at whatever point the
cardiac cycle happens to be in at that moment. If an electrical
shock is provided during the relative refractory period
(corresponding to the latter part of the T wave), it is possible to
induce VF (the so-called “R-on-T Phenomenon”). This would
result in a patient who originally had a pulse being put into cardiac
arrest.
Cardioversion is usually done in the hospital. A care
provider will insert an IV into your forearm or hand and
give you medications called a sedative to help you sleep
during the procedure.
If you're having chemical cardioversion, you'll receive
medications through the IV to help restore your heart
rhythm.
If you're having electrical cardioversion, a care provider
places several large patches (called sensors, or
electrodes) on your chest and sometimes your back.
Wires connect the sensors to a cardioversion machine.
The machine records your heart rhythm. It delivers
quick, low-energy shocks to the heart to restore a
regular heart rhythm.
Electric cardioversion usually takes only a few minutes
to complete.
After the procedure
You'll spend an hour or so in a recovery room being
closely monitored for potential complications.
If electric cardioversion was a scheduled procedure, you
can usually go home the same day. You'll need someone
to drive you home. After cardioversion, your ability to
make decisions may be affected for several hours.
Blood-thinning medications are usually taken for several
weeks after cardioversion to prevent clots from forming.
You'll need blood thinners even if no clots were found in
your heart before the procedure.
Results
For most people, cardioversion can quickly restore a
regular heartbeat. Some people need additional
procedures to keep a regular heart rhythm.
Your health care provider may suggest lifestyle changes
to improve your heart health and prevent or treat
conditions — such as high blood pressure — that can
cause irregular heartbeats (arrhythmias).
Try these heart-healthy lifestyle changes:
● Limit or avoid alcohol
● Use less salt, which can help lower
blood pressure
● Choose whole grains, lean meat, low-fat
dairy, and fruits and vegetables
● Limit sugar and saturated fat and trans
fats
● Increase physical activity
● Maintain a healthy weight
● Quit smoking
● Try to limit or manage stress and anger
Pacemaker
artificial electrical pulse generators that can be temporary or
permanent. They frequently emit a pulse lasting between 0.5
and 25 milliseconds with a voltage between 0.1 to 15 volts and
at a frequency up to 300 per minute.
Transcutaneous cardiac pacing
Attachment
Before applying the patches, the skin site should be
cleansed with soap and water; alcohol and other
flammable liquids should be avoided. In patients with
excessive body hair, trimming rather than shaving is
preferred to avoid tiny skin nicks that can increase pain
and skin irritation.
Do cell phones interfere with pacemakers or ICDs?
Cell phones available in the U.S. (less than 3 watts) do
not appear to interfere with or damage pacemakers.
However, it's best to avoid keeping your cell phone in
your breast pocket on the side of the device. And, use
the phone on the opposite ear, as well.
Do pacemakers or ICDs need to be adjusted periodically?
Some devices may need to be adjusted if your medical
condition or lifestyle changes. Most adjustments are
done using a device called a programmer. This is a
specialized computer that communicates with the
pacemaker or ICD using magnetic signals via a "wand"
or loop placed over your chest where the device is
implanted. Your doctor will instruct you about the
schedule of follow-up visits you should keep based on
your condition and type of device. You may have an
assessment using a monitor and telephone line or an
internet connection on a periodic basis. Most current
ICDs and some pacemakers can now be followed
remotely. This means the device can wirelessly transmit
data to your doctor.
When replacing a pacemaker or ICD, are the leads also replaced?
If the original leads are working properly, in most cases,
they will be left in place and reattached to the new
device.
When do I have to replace my pacemaker or ICD?
Most device batteries will last at least 5 to 7 years,
depending on use. After that time, the battery or pulse
generator will need to be replaced. Replacing a
pacemaker generator may be done on an outpatient
basis or may include an overnight stay in the hospital.
Can I travel with my pacemaker or ICD?
Yes, you can travel by air with your device and drive a
car, if cleared by your doctor. Airport security detectors
are generally safe, but let airport security staff know you
have a pacemaker/ICD and discuss the appropriate
screening procedure. If selected to be screened by
handheld wand, politely remind the screener that these
wands should not be held over the device area for more
than a few seconds. You should be sure to always have
your identification card with you wherever you go. Some
people with ICDs may not be allowed to drive unless
cleared by their doctor. For your safety, and the safety of
others, your doctor may recommend that you do not
drive for 6 months after your ICD is implanted, or after
an ICD discharge. The life threatening heart arrhythmias
that these devices treat can cause you to lose
consciousness, which is dangerous if your are driving.

Can I exercise with a pacemaker?

You may be able to exercise with your pacemaker or
ICD, but check with your doctor first to make sure the
form of exercise you do will not damage the device.

Will I feel the pacemaker or ICD?

At first, you may feel the weight of the device in your
chest. But, over time, most people get used to it. The
device generator is very small, about the size of two
small silver dollars stacked on top of each other, and
weighs about an ounce or less, depending on the make
and model of the device. ICDs are typically slightly
larger than a pacemaker. If the device feels loose or
wiggles in the pocket under the skin, report this to your
healthcare provider. Excessive movement can cause a
detachment of the generator from the wires, or the wires
from the heart muscle, and the device will not work
properly. If the ICD sends a shock to the heart or "fires,"
you will feel this as a jolt or kick in the chest.

Sometimes the placement of the ICD wires can stimulate

nerves that cause the diaphragm to twitch of the
diaphragm and nonstop hiccups or twitching of the
chest muscles. If this happens, call your healthcare
provider.

Can I have an MRI with my pacemaker or ICD?

When you have a pacemaker implanted, stay away from
devices with large magnets or magnetic fields that can
be created from motors of cars or boats. An MRI is a
diagnostic imaging tool used to take images of your
body using magnets. Some pacemaker and ICD devices
are approved to have an MRI but always talk with your
provider before having this test to make sure it is safe
for you. Magnetic fields can be created by other
machines which could affect the normal function of your
device. Avoid high-voltage radar machines, such as
radio or T.V. transmitters, electric arc welders,
high-tension wires, radar installations, or smelting
furnaces.