What is the appropriate management plan for a patient with a functional rhythm and a temporary pacemaker?

SOAP Note for Functional Rhythm with Temporary Pacemaker

Subjective

• Document symptoms of bradycardia: syncope, presyncope, altered mental status, ischemic chest discomfort, acute heart failure signs, hypotension, or signs of shock 1
• Assess pacing dependency: history of symptomatic bradyarrhythmia requiring pacemaker implantation, history of successful atrioventricular nodal ablation, or inadequate escape rhythm at lowest programmable pacing rate 1
• Identify reversible causes: recent cardiac surgery, myocardial infarction, medication effects (beta-blockers, calcium channel blockers, digoxin), electrolyte abnormalities, or myocarditis 1
• Determine functional status: ability to ambulate, presence of fatigue, dizziness, or exercise intolerance 2

Objective

• Vital signs: document heart rate (functional rhythm typically 40-60 bpm), blood pressure, oxygen saturation, and hemodynamic stability 1
• 12-lead ECG: confirm functional rhythm (narrow QRS complexes at 40-60 bpm with absent or retrograde P waves), assess for QT prolongation, and evaluate underlying conduction disease 1
• Pacemaker settings: document mode (typically VVI for temporary pacing), rate setting, output (mA), sensitivity (mV), and verify capture on monitor 1, 3
• Pacemaker function check: verify electrical capture (pacing spike followed by QRS), mechanical capture (palpable pulse or arterial waveform with each paced beat), and sensing function 1, 3
• Physical examination: inspect insertion site for signs of infection (erythema, warmth, drainage), palpate peripheral pulses, assess for signs of heart failure, and check for lead displacement 4, 3
• Laboratory data: electrolytes (potassium, magnesium, calcium), complete blood count, troponin if acute coronary syndrome suspected 1

Assessment

Functional rhythm with temporary transvenous pacemaker in place

• Hemodynamic status: stable versus unstable (determines urgency of permanent pacemaker placement) 1
• Pacing dependency: pacemaker-dependent (no escape rhythm or inadequate escape rhythm) versus non-dependent 1
• Reversibility assessment: transient/reversible cause (medication effect, electrolyte abnormality, acute myocarditis) versus permanent conduction disease 1
• Duration of temporary pacing: document days since insertion (infection risk increases with duration, transition to permanent device typically within 2-19 days) 5
• Complications: lead dislodgement risk 16% (50% within first 24 hours), infection risk increased with prolonged temporary pacing, venous thrombosis 5, 4

Plan

Immediate Management

• Continuous cardiac monitoring: mandatory for all patients with temporary pacemakers until device removal or replacement (Class I recommendation) 1, 5
• Monitor peripheral pulse: use pulse oximetry plethysmogram or arterial line in addition to ECG monitoring to confirm mechanical capture 1
• Verify pacemaker function: check capture threshold daily, ensure adequate safety margin (typically set output at 2-3 times threshold), verify sensing function 3
• Optimize pacemaker settings: maintain rate 60-80 bpm for hemodynamic stability, adjust sensitivity to prevent oversensing from large P/T waves or electrical interference 1, 5

Definitive Management Decision Algorithm

If reversible cause identified:

• Complete resolution with treatment: permanent pacing should NOT be performed (Class III: Harm) 1
• Persistent block despite treatment: permanent pacing is recommended (Class I) 1
• Acute myocarditis with symptomatic bradycardia: temporary pacemaker indicated during acute phase, permanent device contraindicated until resolution (Class III: Harm during acute phase) 1

If irreversible/permanent conduction disease:

• Hemodynamically unstable refractory to medical therapy: proceed to permanent pacemaker implantation once stabilized 1
• Persistent complete heart block with pre-existing right bundle branch block: consider same-day permanent pacemaker 5
• Standard timeframe: transition to permanent device within 2-19 days based on clinical stability and infection risk rather than arbitrary time limits 5

Infection Prevention

• Minimize duration: replace temporary pacemaker with permanent device or remove as soon as clinically feasible (presence of temporary wire before permanent implantation increases infection risk) 5
• Daily inspection: assess insertion site for erythema, warmth, drainage, or tenderness 4, 3
• Sterile technique: maintain during all pacemaker checks and dressing changes 3

Lead Management

• Secure lead position: ensure adequate fixation to prevent dislodgement (active fixation leads preferred over passive fixation for prolonged temporary pacing) 5, 4
• Avoid lead manipulation: minimize unnecessary handling to reduce dislodgement risk 4
• Consider externalized permanent active fixation lead: if prolonged temporary pacing required (>24-48 hours), use externalized permanent lead rather than standard passive fixation temporary lead (Class IIa) 1

Troubleshooting Common Problems

• Loss of capture: increase output, reposition patient, verify lead-generator connection, check battery, rule out lead dislodgement with chest X-ray 5, 3
• Oversensing: decrease sensitivity, rule out electrical interference from faulty equipment or muscle artifact 1, 5
• Undersensing: increase sensitivity, verify adequate intrinsic signal amplitude 3
• Large pacing artifact obscuring QRS: try different ECG monitoring leads, use concomitant pulse oximetry or arterial pressure monitoring to confirm mechanical capture 1

Disposition and Follow-up

• Cardiology consultation: for permanent pacemaker evaluation if conduction disease persists beyond reversible cause treatment 1
• Telemetry monitoring: continue until temporary pacemaker removed or replaced with permanent device 1, 5
• Activity restriction: bed rest with passive fixation leads, ambulation permitted with active fixation leads 4
• Temporary pacing equipment availability: maintain defibrillation and backup temporary pacing equipment immediately available 1