CPR on Patients with Cardiac Pacemakers
Yes, perform standard CPR immediately on any patient with a pacemaker who is in cardiac arrest—the presence of a pacemaker does not change CPR technique, and you should never delay or withhold chest compressions due to concerns about damaging the device. 1
Standard CPR Protocol Without Modification
- Initiate high-quality chest compressions immediately at 100-120 compressions per minute with a depth of at least 2 inches (5 cm), allowing complete chest recoil between compressions. 1
- 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
- All patients in cardiac arrest should receive chest compressions regardless of implanted devices, as effective chest compressions are essential for providing blood flow during CPR. 2
The evidence is unequivocal here: 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
Defibrillation Considerations
When defibrillation is needed, place pads at least 8 cm away from the pacemaker generator if possible, but never delay shock delivery to achieve ideal positioning. 1
- Acceptable pad placements include anterior-posterior and anterior-lateral positions on the chest wall. 1
- The risk of pacemaker or ICD malfunction after external defibrillation when pads are placed close to the device generator is acceptable given the alternative is death. 1
- Case series have reported pacemaker or ICD malfunction after external defibrillation when pads were placed in close proximity to the device generator, but this should not prevent defibrillation. 2
- For witnessed adult cardiac arrest when an AED is immediately available, use the defibrillator as soon as possible. 2
Potential Device Interference
- Pacemaker spikes generated by devices programmed to unipolar pacing may confuse AED software and emergency personnel and may prevent detection of ventricular fibrillation. 2, 3
- If the AED fails to recognize VF in a patient with a pacemaker, manually assess the rhythm and proceed with defibrillation based on clinical judgment. 3
Special Circumstances: Epicardial Pacing Wires
If the patient has epicardial pacing wires already in place (typically post-cardiac surgery patients), attempt immediate pacing for asystole or bradycardic arrest, but initiate CPR if pacing is not successful within 1 minute. 2, 1
- In a trained provider-witnessed arrest of a post-cardiac surgery patient where pacer wires are already in place, immediate pacing is recommended for asystolic or bradycardic arrest. 2
- Electric pacing is not effective as routine treatment in patients with asystolic cardiac arrest who do not have pre-existing pacing wires. 2
Post-Shock Management
Resume chest compressions immediately after shock delivery without pausing for rhythm or pulse checks. 2
- After defibrillation attempts, the majority of patients remain pulseless for over 2 minutes, and the duration of asystole before return of pulses is longer than 120 seconds in as many as 25% of cases. 4
- The mean time to return of spontaneous circulation after defibrillation is approximately 136 seconds (median), supporting the recommendation to immediately resume chest compressions for 2 minutes following attempted defibrillation. 4
Critical Pitfall to Avoid
Never withhold or delay CPR due to concerns about damaging the pacemaker device. 1 This is the most common error in managing cardiac arrest in patients with pacemakers. The device can be replaced or reprogrammed after successful resuscitation, but the patient cannot be revived if CPR is delayed or withheld.