slideset from this talk http://emergencymedicineireland.com/2012/08/blackouts-and-syncope/

2. Pacemakers and their problems
Sept 2013

3. Indications
•Symptomatic heart block
•Symptomatic sinus brady
•AF with symptomatic brady
Also:
•Cardiac Resynchronization Therapy
•Defibs

4. Device =
Mode =

5. Normal: atria and ventricle paced

6. Normal: ventricle paced

9. WhoCares?

10. http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-
september-2013_18.html
http://lifeinthefastlane.com/ecg-library/pacemaker/

11. https://gmep.org/media

12. http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-
september-2013_18.html

13. Problems
Early:
•Infection
•Bleeding
•Lead misplacement
•Pacemaker syndrome
(poor coordination)
•thrombosis
Late:
•Battery
•failure
•runaway pacemaker
•Lead Fracture
•Skin Erosion
•‘Twiddler’s syndrome’
•thrombosis (usually chronic and
not a problem)
General:
•Mis-sensing
•Pacemaker mediated tachy

14. Pacemaker mediated tachy [=AVRT]
http://lifeinthefastlane.com/ecg-library/pacemaker-malfunction/

15. Runaway pacemaker

17. Magnet Mode

18. Lead Fracture

19. Falls & Blackouts
April 2012

20. Falls and blackouts
Acknowledgements/images
•Life in the fast lane
•Sonocloud.org
•Andy Buck
•the wonders ofYouTube and Wiki
•Amal Mattu

21. Falls and Blackouts
Blackout/Syncope
Falls
http://www.youtube.com/watch?v=DU_i0ZzIV5U

22. Blackouts/Syncope
Serious Benign
•Cardiac
•HOCM
•Brugada
•ARVH
•QT
•AS
•Arrhythmias...
•PE
•Aortic
•Ectopic
•SAH
•Seizure
•?TIA
•Neurocardiogenic/vasovagal/faint
•Meds
•Micturition/Cough syncope
•Necktie/Shaving syncope

23. Cardiac
•sudden
•palpitations
•chest pain
•witnessed
•? LOC
•? murmur
•vital signs (RR!)
•cognition
•neuro
ECG
? Blood Sugar
History Exam

24. HOCM

27. HOCM

30. Brugada
•Likely common cause of SCD
•ICD only treatment
•presence of symptoms is important
•Quoted 10% mortality a year if untreated (though recent evidence
questions this...)
PMID 20100972

31. RBBB Brugada Brugada

33. Orthodromic Antidromic

34. Normal AF WPW AF

36. Long QT
•Just use the calculated QTc
•>500ms before badness happens
Causes
•Syndrome - rare
•Low electrolytes
•All the drugs in the world...

37. CHESS

38. San Fran/CHESS
The rule performed with a sensitivity of 90% (44/49 outcomes; 95%
confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to
34%).
Rule performance to predict serious outcomes was sensitivity 74% (95% CI
61% to 84%), specificity 57% (95% CI 53% to 61%)
The rule was 98% sensitive (95% confidence interval [CI] 89% to 100%) and
56% specific (95% CI 52% to 60%) to predict these events.

40. Falls in the elderly
Serious Benign
•Everything... •Nothing...

41. ACS
•Common
•Usually with an associated “anginal equivalent” (lethargy,
diaphoresis, shortness of breath)
•If isolated blackout with no symptoms prior or after then
unlikely (quoted <1% pick up rate for trops in syncope)
•Difficulty given baseline ECG changes and renal function

42. Found on the floor...
•Rhabdo
•Hypothermia
•Fractures

43. If they’re now back to baseline?
PMID: 17200478

44. Risk Assessment
Timed up and go [>20 secs abnormal]
http://www.youtube.com/watch?v=dsTfqk9ZTiw

45. As yet...
There is no good, reliable test
•Risk assessment
•Gait assessment
•Have they fallen in the past year
•Falls clinic/assessment

46. Driving regulations?
Provoked: