Pacer pads and automated implantable cardioverter defibrillator in intubated patient

Case contributed by Kirollos Bechay

Presentation

Intubated patient with history of acute hypoxic respiratory failure, atrial fibrillation and congestive heart failure.

Patient Data

Age: 60 years
Gender: Female

1. The single lead left-sided automated implantable cardioverter defibrillator (AICD) and its lead are in the appropriate positions.  The tip of the left internal jugular central venous catheter is seen in the region of the junction of the right and left brachiocephalic veins and is obscured due to overlying leads and wires. The tip of the right left internal jugular central venous catheter terminates in the region of the proximal superior vena cava. Overlying tubes, leads, wires, and pacer pads obscure details limiting evaluation.

2. Overall moderate bilateral lung aeration in this patient with diffuse bilateral coarse interstitial reticular and patchy ground-glass airspace opacifications, left greater than the right. No discrete large effusion on the left or pneumothorax on either side. Severe cardiomegaly.

Case Discussion

Pacer pads are devices used for transcutaneous pacemakers, which regulate heart rate to maintain cardiac output via electricity externally applied above the skin. These devices are the fastest method to treat bradyarrhythmias, which is their major indication 1. Transcutaneous pacing is a temporary method that is applied until a permanent pacemaker can be placed or when a permanent pacemaker is contraindicated. Pacer pads are usually positioned with a negatively-charged pad at the apex of the heart and a positively-charged pad in the parasternal or subscapular region.

In this patient, a negative pad was placed at the apex and a positive pad was placed in the parasternal region, as seen in the diagram above. Transcutaneous pacemakers are contraindicated in hemodynamically stable patients, as they can reduce stroke volume significantly 2. Studies suggest that transcutaneous pacemaking have similar hemodynamic benefits as internal right ventricular pacing but improvement to patient outcomes has so far been inconclusive 3

This case was submitted with supervision and input from:
Soni C. Chawla, M.D.
Health Sciences Clinical Professor,
Department of Radiological Sciences,
David Geffen School of Medicine at UCLA.
Attending Radiologist,
Olive View - UCLA Medical Center.

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