CPR on Patients with Pacemakers
Yes, perform standard CPR immediately on any patient with a pacemaker who is in cardiac arrest—the presence of a pacemaker does not contraindicate or modify chest compressions, and the life-saving benefit far outweighs any theoretical risk of device damage. 1
Standard CPR Protocol Applies
Initiate high-quality chest compressions immediately at 100-120 compressions per minute with depth of at least 2 inches, allowing complete chest recoil between compressions. 1, 2
The American Heart Association guidelines make no distinction or modification to CPR technique based on the presence of a pacemaker or implantable cardioverter-defibrillator (ICD). 1
Minimize interruptions in chest compressions, as any pause reduces coronary perfusion pressure and decreases likelihood of return of spontaneous circulation (ROSC). 2
Defibrillation Considerations with Pacemakers
When defibrillation is needed, place pads/paddles at least 8 cm away from the pacemaker generator if possible, but do not delay shock delivery to achieve ideal positioning. 1
Acceptable pad placements include anterior-posterior and anterior-lateral positions on the chest wall. 1
Two case series documented pacemaker or ICD malfunction after external defibrillation when pads were placed in close proximity to the device generator, but this risk is acceptable given the alternative is death. 1
After successful defibrillation, check pacemaker function as devices may require reprogramming, but this is a post-resuscitation concern, not a reason to withhold defibrillation. 1
Device-Specific Interventions
If the patient has epicardial pacing wires already in place (such as post-cardiac surgery patients), attempt immediate pacing for asystole or bradycardic arrest, but initiate CPR if pacing is not successful within 1 minute. 1, 3
Be aware that pacemaker spikes from devices programmed to unipolar pacing may confuse automated external defibrillator (AED) software and could potentially prevent detection of ventricular fibrillation—manually verify the rhythm if there is any doubt. 1
Common Pitfalls to Avoid
Never withhold or delay CPR due to concerns about damaging the pacemaker device—case reports have rarely described damage to implanted devices from external chest compressions, but the certain death without CPR far outweighs this minimal risk. 1
Do not waste time trying to achieve "perfect" pad placement away from the device during cardiac arrest—immediate defibrillation takes priority over optimal positioning. 1
Do not assume the pacemaker is functioning during cardiac arrest just because you see pacemaker spikes on the monitor—this may represent electrical activity without mechanical capture (a form of pulseless electrical activity). 1