 Welcome to nursing school explain in this video about pacemakers. First of all, if you haven't already done so, I highly recommend watching my basic EKG interpretation series as well as all the videos about the indications of pacemakers that I'll go over here in a little bit so that you understand what the underlying rhythm is that requires a pacemaker to be inserted. Secondly, there are basically three types of pacemakers and that just depends on the severity of the patient's symptoms and the severity of the heart block or the radiocardial that the patient is experiencing that requires them to have a pacemaker. So many times if a patient becomes symptomatic out of the hospital, they will be brought into the emergency department by the pre-hospital providers and depending on what county that you're working at, they have certain protocols that they follow. Most likely if they determine that there's an underlying condition, then they will transcutaneously pace the patient. The gap or the bridge between transcutaneous and permanent pacemaker is called transvenous pacemaking and I'll go over all three of these. Now, indications for pacemakers I've listed over here in red. So there can be any kind of atrial ventricular block, mostly the higher degree block such as second and third degree and acute MI that's causing some sort of a damage to the patient's intrinsic conduction system. Sinus node dysfunction. So now in the SA node, the intrinsic pacemaker is not functioning and firing. We don't have the electrical conduction going through the heart. It can be used in the prevention and treatment of tachyarythmias and those will be any of the potentially lethal tachycardia or tachyarythmias such as ventricular tachycardia and ventricular fibrillation. And I put in parentheses here AICD so many times pacemakers can be combined with a automatic internal cardioverter and defibrillator that will basically then be able to shock the patient out of this tachyarythmia. When there are repeated episodes of syncope that are maybe due to some conduction problem and for cardiomyopathies, if that hard muscle has become so weak that now the patient requires a pacemaker just to support the patient's underlying conduction system and hard function to help with the contraction of the muscle. And when we talk about permanent pacemakers, there are two different ones which are synchronous or asynchronous. There are sometimes also called demand and fixed rate pacemakers. So a synchronous pacemaker only fires when the intrinsic heart rate goes below a certain threshold. So this patient might be suffering from a sinus node dysfunction but sometimes the sinus node might still be working. So now if the patient's intrinsic heart rate goes below let's say 60, the pacemaker will kick in but if it's above 60 then the regular conduction system, the intrinsic conduction system of the patient will initiate the contraction. And then for asynchronous or fixed rate pacemakers there is a preset rate but those are very rare because most likely the conduction system of the patient will still work to a certain degree and these synchronous and demand pacemakers are more common. Now if we're talking about back to the pre-hospital setting when a patient requires a pacemaker in the field, the paramedics can't just magically insert that underneath their skin so the bridge to a permanent pacemaker is through transcutaneous pacing and that is only done in an emergency and it uses the defibrillator that is used in the emergency setting. So the defibrillator has many different functions or options to do and one of them is pacing and transcutaneous meaning through the skin we use the same defibrillator pads that you would use for your AED as you might be familiar with from your CPR class or the defibrillator pads that we usually use to defibrillate patients that are the lethal tachyarhythmia for example. And so these pads basically deliver the electricity through the skin and on the defibrillator itself we'll get the underlying rhythm and then there's usually a button for defibrillation, cardioversion and then there are usually two buttons that go into rate and amplitude which are those pacemaker settings. And you can set the rate usually between 60-80 beats per minute and the amps meaning that the strength of the electrical conduction that is transmitted through these two pads. Usually we start at 30 and then work our way up to see when capture occurs and not go into that a little bit later. And I put here sedation if amps greater than 50 are required. So imagine somebody puts two pads on you and they shock you from the outside with these pacing pads. Now the higher the amplitude the more painful that will be so many times the patient is given a sedative such as versed or addigan to kind of calm them down and also deal with the pain that that causes. And again this is only done in the emergency setting so then the patient will come to the emergency room and the provider there will insert a transvenous pacer. And so now we're going from transcutaneous to transvenous and that is basically a temporary solution again but it's much better than these external pads that we have on the patient. And transvenous pacing is the same as a central line insertion it's usually done at the jugular or less likely also at the femoral site. And so that catheter is inserted at the jugular vein and there are usually two parts that are needed which are an introducer and then the sheet which allows the wire of that transvenous pacing to be guided into the patient's heart. And as you can see here I draw out the patient's heart and through the central line the pacemaker is guided into the atrium or the ventricle depending on the patient's knee most likely it will be the ventricle. And from there internally it gives out the electrical impulse that helps to pace the patient. Again only a temporary solution. Now the pacemaker here looks a little bit different and every facility has different temporary pacemakers that they use but they all will have doubts for rates. Again that we can set amplitude and then sensitivity which means how sensitive it is to the patient's intrinsic heart rate kind of similar to the synchronous or demand pacing I just discussed over here. Now when the patient has this transvenous spacer inserted they will most likely go to the intensive care unit where the nurses are very familiar with these devices can monitor the patient, make sure everything is working that it's producing the cognitive output and plug pressure that will not in this patient until a permanent pacemaker can be inserted. And then so over here the permanent pacemaker is usually implanted over the pectoral muscle which is usually on the left side of the chest but it can also sit on the right side. And then the leads from that implanted pacemaker that sits underneath the skin the leads are inserted into the heart. So either in the right atrium and or one of both ventricles depending again on the patient's needs. And so I've drawn out here this pacemaker that a lot of times you can feel underneath. Many times or often it is also an AICD that just in case if a lethal arrhythmia occurs the device will sense that and then will internally shock the patient out of that lethal rhythm just like we would do in our advanced cardiac life support with our defibrillator or even with the AED in basic life support. So over here what does pacing look like on an EKG so depending on what is needed and where the pacemaker sits we will either have the electricity firing in the atrium or in the ventricles or maybe both. So if there's atrial pacing on an EKG we have our P, Q, RS and then T waves. And remember atria always represent the P wave or the other way around P wave represents atrial contraction. So we'll see the spacer spike. So it's this vertical line that occurs right before the P wave. And that is basically the artificial pacing, the artificial electrical impulse whatever pacemaker is emitting into the patient's heart and then it follows by the P wave meaning atrial contraction and then followed by the Q, RS and then the T wave. So every time before the P wave here we have the spacer spike meaning now this is atrial pacing. Now ventricular pacing very similar except that here now we have that vertical pacer spike here in pink not before the P wave but in front of the Q, RS complex. So every time we have that pacer spike the Q, RS follows pacer spike Q, RS follows. So this is the impulse that we are giving the patient and then the hard response by the contraction of the ventricles that's represented by the Q, RS complex. Now that can also be AB sequential pacing which basically means atria and ventricles they are contracting in sequence. And so now we have two pacer spikes one before the P wave one before the Q, RS complex and meaning that both that there is now dual leads one sitting in the atria one in the ventricle and they're each causing the contraction of the different chambers. Now when a pacemaker first is inserted and let's say this is for a severe sinus spray cardia or maybe one of those heart blocks that we talked about. So the patient here will have their sinus spray cardia and they will have a normal beat but then there's a long gap and we have just inserted a pacemaker. And then we will see the pacer spike that we also see here but you see there's no capture meaning that no contraction of the heart follows. So we just have these blank pacer spikes which basically means that the electrical conduction is happening but the heart muscle is not responding by contracting. And that usually means that the amplitude the strength of the contraction that we talked about over here is not enough. So then when either one of these or actually even with the permanent pacemaker is inserted and the provider is trying to dial in the note that we get capture meaning that we now can get the heart to contract. So we dial up the amplitude here a little bit. Let's say we started 30 we don't get anything we have a pacer spike nothing we dial it up to 40 still no capture without it up to 50 still no capture without it up to 60. Oh look at that. Now we have a pacer spike followed by a qrs which means that now we're capturing so now the amplitude the strength of the contraction is strong enough to stimulate the cardiac muscle cells to contract and to produce that cardiac output because clearly nothing is happening here. We have to set these pacer spikes with no response. So thank you for watching this video on pacemakers. I hope this has cleared up your understanding of the different modalities transcutaneous transvenous and the permanent pacemakers. Please give me a thumbs up if you liked this video also follow me on Instagram where I have study tips and always announce the latest videos. Thanks for watching Nursing School Explained. See you soon.