A Change of Pace: Modifying Pacemaker Settings in the Emergency Department as Emergency Medicine Physicians, A Case Report

Abstract

Background: Pacemakers are implantable or external devices that send electrical impulses allowing the heart to contract. Some common indications for permanent pacemaker placement include symptomatic bradycardia due to high grade atrioventricular (AV) block, sick sinus syndrome, chronic bifascicular block, and post-cardiac transplantation. Like all devices pacemakers can malfunction or stop working entirely. We present a patient with an implantable pacemaker/cardioverter and defibrillator (ICD) displaying symptomatic failure to capture and settings were adjusted in the emergency department. Adjustment in the emergency department (ED) resolved the patient's symptoms and required no further interventions.Case Report: An 82-year-old female with atrial fibrillation, heart failure, and a Medtronic dual chamber pacer/ICD presented to the emergency department for complaints of weakness and lightheadedness. Emergency medical services (EMS) noted intermittent bradycardia, hypotension, and decreased responsiveness. Electrocardiogram (ECG) revealed failure to capture. The Medtronic application was used to interrogate and reprogram the device. The settings were DDD at a rate of 60 beats per minute (BPM) with ventricular output of 4.5 millivolts (mV) and atrial output of 4.5 mV which were changed ventricular lead outputs from 4.5 mV to 8.0 mV and rate from 60 to 80 for additional cardiac output. After this adjustment, the bradycardia resolved, and ECG showed a successful AV-paced rhythm. Transcutaneous pacing was never required.Why should an emergency physician be aware of this?Adjustment of pacer settings in the ED in order to stabilize the critically ill patient is within the scope of the emergency physician. We can reduce stress to the patient and prevent hospitalizations. Pacemakers can become a tool to optimize treatment plans for an aging population where pacemakers are becoming more common.