Written by Dr. Toby Mathew (PGY2), Dr. Neal Richmond, and Dr. Michael Halperin
A 79-year-old female with a past medical history of DM, HTN, HLD, dementia, and left breast cancer s/p lumpectomy presented to the emergency room with altered mental status and a fall. According to the family, the patient is alert and oriented x1 at baseline but lives alone. The family found the patient on the ground around 2 pm after last seeing her around 11 am.
Upon arrival, the patient's vitals revealed a temperature of 98.0F, bradycardic to 32, respiratory rate of 18, and oxygen saturation of 98%. It was extremely difficult to obtain blood pressure manually or through the machine.
On the physical exam, the patient was disoriented and only responded to physical stimuli. The patient heart was regular and bradycardic with no murmurs, rubs, or gallops. She had clear breath sounds, and her abdomen was soft and nontender. Distal pulses 2+ in all extremities with mild 1+ pitting edema in lower extremities. An EKG revealed sinus bradycardia.
Initial ECG
A right radial arterial line was placed to obtain accurate blood pressure monitoring as the cuff pressures would vary. After successful placement, she was found to be hypotensive to 80/50. 1mg of atropine was given twice without response. The patient was then started on transcutaneous pacing without response. Cardiology was consulted that recommended starting isoproterenol and placing a transvenous pacer (TVP). An ultrasound-guided cordis was placed in the right internal jugular with no immediate complications. The port demonstrated good blood return and flushed easily. The patient was attached to EKG and an ultrasound was used to guide TVP placement. As the TVP is advanced we were able to see ST elevations as the pacer wire advances into the right ventricle. We could also see the wire in the right ventricle on the ultrasound.
Ultrasound Procedural Guidance - TVP Wire entering right atrium
Ultrasound Procedural Guidance - TVP Wire entering right ventricle
The pacer had good capture and heart rate improved to 60s. She remained hypotensive and was started on norepinephrine.
Post-Procedure ECG
Our patient's course was complicated by our patient exhibiting episodes of agonal breathing and hypoxia. She was subsequently intubated for airway protection. Chest Xray revealed proper placement of TVP and endotracheal tube along with bilateral consolidations. The patient was brought to the cardiac care unit for further care.
Transvenous pacing is indicated for severe bradyarrythmias, like unstable bradycardia, AV block, digoxin toxicity, overdrive pacing, and sick sinus with pauses. A few complications can be related to central venous access, like pneumothorax, infection, air embolism, and arterial puncture, or pacing catheter placement, like valvular rupture or myocardial perforation. Transvenous pacing is a temporary bridge, until the bradyarrythmias resolve or a permanent pacemaker is placed.
Comments