Pacemakers
Your patient is presenting for a right shoulder arthroscopy, they have a PMH of DM, Afib, HTN, and pacemaker implantation. The patient tells you they have an AOO pacemaker, you know that this means?
A. Only the atrium is paced, sensed, and responded to
B. Only the ventricle is paced, sensed, and responded to
C. The atrium is paced, but not sensed or responded to
D. The pacemaker will be inhibited if it senses the patients intrinsic electrical activity
C
Match the pacemaker position code to its designated function:
Position #1 Response to sensed event
Position #2 Chamber paced
Position #3 Programmability/rate modulation
Position #4 Chamber sensed
Position #1/first letter = Chamber paced
Position #2/second letter = Chamber sensed
Position #3/third letter = response to sensed event
Position #4/fourth letter = Programmability/rate modulation
In the patient with an ICD or pacemaker, the SRNA should be aware that all of the following are possible effects of electromagnetic interference except?
A. Endocardial burns
B. Hyperthermia
C. Loss of atrial kick
D. Decreased battery life
B
When inserting a central line in the RIJ, how far should you advance the catheter to achieve correct placement?
A. 10cm
B. 15cm
C. 20cm
D. 25cm
B, CVC should rest at the junction of the vena cava and right atrium (15cm), and should not enter the RA (15-25cm)
True or false: The SRNA must wear a hat, mask, sterile gloves and sterile gown during the placement of a central venous catheter?
True, CVC placement is always sterile. Full body sterile drape on patient is required as well. Biopatch is a good addition.
Other notes:
Clean with chlorhexidine
Close proximity of carotid to IJ can result in inadvertent arterial placement
Place pt in trendelenberg to prevent air embolism and distend vein
Placement confirmed with CXRAY
US guidance is popular/mainstay practice
Which of the following pacemakers only paces the atrium, senses the atrium, and pacemaker activity is inhibited by intrinsic electrical activity sensed in the atria?
A. AAA
B. DDD
C. VVI
D. AAI
D
All of the following are examples of asynchronous pacing except:
A. AOO
B. VOO
C. BOO
D. DOO
C
AAI & VVI are single chamber pacing
The SRNA knows that which of the following are appropriate actions if they are using a magnet intraoperatively for reprogramming of a pacemaker or ICD? (SATA)
A. Ask the patient preoperatively what their underlying rhythm is in case of device failure
B. Have the crash cart nearby and place transthoracic pacing pads
C. The patient must have postoperative interrogation of their device
D. They can bring their favorite fridge magnet from home for use
A, B, & C
When inserting a pulmonary artery catheter, what changes in your waveform tracing would indicate that you have entered the right ventricle?
A. A sudden increase in the diastolic pressure
B. A sudden increase in the systolic pressure
C. The presence of a dicrotic notch
D. The presence of A, C, & V waves
B
All of the following are true regarding the placement and monitoring of pulmonary artery catheters except:
A. Placement is contraindicated in patients with a left bundle branch block
B. If using the right internal jugular site, distance to the pulmonary artery is 30cm
C. PA rupture is a complication of placement and can present as trace hemoptysis
D. If using the subclavian site, distance to the right atrium is 10cm
B, distance to PA is 35-45cm
Distance to right ventricle is 25-35
A, true, can cause complete heart block since entering R side of heart
When a patients pacemaker is oversensing and interpreting electromagnetic interference as intrinsic electrical activity, how will the pacemaker respond?
A. It will deliver a shock because it senses the interference as ventricular fibrillation
B. The pacemaker will not fire
C. The pacemaker will stop sensing and begin pacing the patients native rhythm
D. The pacemaker will fire at inappropriate times
B
Your patient undergoing a carpel tunnel surgery has a VOO pacemaker with a rate oof 90BPM. During the procedure there is failure to capture, and the patients HR falls to 50BPM. Which of the following BEST explains why this occured?
A. An ultrasonic scalpel was used
B. The patient is hyperthermic
C. The patients EtCO2 is 22mmHg
D. The electrocautery setting was changed from "coagulation" to "cutting"
C, hypocarbia/hypocapnia results in failure to capture (causes hypokalemia, which makes the myocardium more resistant to depolarization)
Match the arterial line placement site with its disadvantage:
Brachial increased risk for infection
Femoral increased risk of air thrombus entering cerebral circulation
Axillary most distorted waveforms
Posterior Tibial increased risk of kinking
Brachial = increased risk for kinking
Femoral = increased risk for infection
Axillary = increased risk of air thrombus entering cerebral circulation
Posterior Tibial = most distorted waveforms
When choosing a site for arterial cannulation, the SRNA knows that which of the following is true?
A. The dorsalis pedis site increases the risk of nerve damage
B. The ulnar site should be avoided if the ipsilateral radial has been punctured but not cannulated
C. The axillary site is large and easily identifiable, and has less waveform distortion d/t closer proximity to the aorta
D. The posterior tibial site is prone to atheroma and pseudoaneurysms
B, ulnar site is also deeper and more tortuous than radial
(Axillary increases risk of nerve damage)
C is true for the brachial artery
D is femoral
If you see this tracing on your PA catheter waveform, what part of the heart have you entered?
https://docs.google.com/document/d/1US0hQ6rSK9eFep1OFR2Y4Nhmheu5Kg_bE6AonxgyWgw/edit?usp=sharing
RA, typical pressure reading 0-8
Can cause some ectopy during this time
Your patient is a 46 y.o. diabetic with gastroparesis undergoing a cholecystectomy, you decide to perform a RSI with succinylcholine. How might this affect the patients pacemaker?
A. It will cause pacemaker failure to capture because the myocardium becomes resistant to depolarization
B. It will alter the myopotential threshold and result in output failure
C. It will result in oversensing and inhibit the pacemaker from firing
D. It will increase the arrhythmogenicity of the myocardium resulting in failure to capture
C, fasciculations from succs sensed as cardiac contractions and pacemaker will not fire (oversensing:inhibition)
Your patient is a 67 y.o. male undergoing a left hip arthroplasty and the surgeon will be using monopolar electrocautery for dissection. What is the best positioning for the bovie grounding pad?
A. The patients right shoulder
B. The patients left lower abdomen
C. The patients left upper arm
D. The patients right scapula
B, the grounding pad should be positioned as close to the surgical site as possible and as far away from the generator as possible.
What is the preferred placement site for a central venous catheter?
A. Right internal jugular
B. Left subclavian
C. Right subclavian
D. Left internal jugular
A
Which of the following is true regarding proper technique when placing a radial arterial line?
A. Alcohol is the preferred skin prep
B. Placement must always be done using sterile technique
C. The artery is located on the lateral aspect of the forearm between the brachioradialis and flexor carpi radialis muscles
D. Enter the skin at a 90 degree angle
C
Chlorhexidine, sometimes aseptic technique, 45 degree angle
If you see this tracing on your PA catheter waveform, what part of the heart have you entered?
https://docs.google.com/document/d/1US0hQ6rSK9eFep1OFR2Y4Nhmheu5Kg_bE6AonxgyWgw/edit?usp=sharing
PA, sudden increase in diastolic pressure indicates you have entered the PA
All of the following are patient conditions that cause of failure to capture of a pacemaker except:
A. Hypothermia
B. Shivering
C. Myocardial infarction
D. Hypokalemia
B (oversensing, inhibits pacing)
All of the following are true when using electrocautery during surgery on a patient with a pacemaker except:
A. If the surgery is above the umbilicus, put a magnet over the patients pacemaker
B. Short bursts of cautery, less than 5 seconds, should be used
C. Bipolar electrocautery is preferred over monopolar as it produces less electrical energy
D. An anode or cathode at the tip of the cautery device increases the chance of stray electrical activity
D, false, less stray electrical activity
What three anatomical structures are you trying to identify when placing a CVC in the IJ to help with visualization of the insertion site? (Select 3)
A. Sternal head of the sternocleidomastoid muscle
B. Clavicle
C. Right tracheoclavicular midline
D. Clavicular head of the sternocleidomastoid muscle
A, B, & D. These 3 make a triangle and the RIJ lies within it
Which of the following is not true when choosing a site for central venous catheter placement?
A. Pacemaker leads and generators may interfere with the use of certain sites
B. RIJ is associated with increased risk of pleural effusion
C. Contraindications to CVC placement include tumors, clots, and tricuspid valve vegetations
D. The subclavian site is relatively contraindicated in patients on anticoagulants
B: LIJ is associated with increased risk of pleural effusion
(D, not a compressible vessel so hematomas are much harder to control, increased risk of pneumothorax with subclavian)
The SRNA knows that all of the following are true when using a magnet on implanted cardiac devices except:
A. If the patient will be prone, place the magnet on the back over the pacemaker site
B. If the patient has a stand alone pacemaker, it will convert the pacemaker to asynchronous pacing
C. If the patient has a stand alone ICD, it will suspend the ICD and prevent shock delivery
D. If the patient has a combined pacemaker and ICD, it will suspend shock delivery and has no effect on pacemaker function/will not convert to asynchronous pacing
A. not sure if she'll ask this but in the lecture she said prone positioning makes using the magnet impossible (doubt this is what we'll see in practice?)