Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.
Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, Washington.
J Emerg Med. 2024 Apr;66(4):e492-e502. doi: 10.1016/j.jemermed.2023.11.018. Epub 2023 Dec 9.
Transvenous pacemaker placement is an integral component of therapy for severe dysrhythmias and a core skill in emergency medicine.
This narrative review provides a focused evaluation of transvenous pacemaker placement in the emergency department setting.
Temporary cardiac pacing can be a life-saving procedure. Indications for pacemaker placement include hemodynamic instability with symptomatic bradycardia secondary to atrioventricular block and sinus node dysfunction; overdrive pacing in unstable tachydysrhythmias, such as torsades de pointes; and failure of transcutaneous pacing. Optimal placement sites include the right internal jugular vein and left subclavian vein. Insertion first includes placement of a central venous catheter. The pacing wire with balloon is then advanced until electromechanical capture is obtained with the pacer in the right ventricle. Ultrasound can be used to guide and confirm lead placement using the subxiphoid or modified subxiphoid approach. The QRS segment will demonstrate ST segment elevation once the pacing wire tip contacts the endocardial wall. If mechanical capture is not achieved with initial placement of the transvenous pacer, the clinician must consider several potential issues and use an approach to evaluating the equipment and correcting any malfunction. Although life-saving in the appropriate patient, complications may occur from central venous access, right heart catheterization, and the pacing wire.
An understanding of transvenous pacemaker placement is essential for emergency clinicians.
经静脉起搏器放置是治疗严重心律失常的重要组成部分，也是急诊医学的核心技能。
本叙述性综述对急诊科经静脉起搏器放置进行了重点评估。
临时心脏起搏是一种救生程序。起搏器放置的指征包括因房室传导阻滞和窦房结功能障碍导致的有症状心动过缓引起的血流动力学不稳定；不稳定的心动过速（如尖端扭转型室性心动过速）的超速起搏；以及经皮起搏失败。最佳放置部位包括右侧颈内静脉和左侧锁骨下静脉。首先插入中心静脉导管。然后推进带有气囊的起搏线，直到起搏器在右心室获得机电捕获。超声可用于引导和确认使用剑突下或改良剑突下方法的导联放置。一旦起搏线尖端接触心内膜壁，QRS 段将显示 ST 段抬高。如果经静脉起搏器的初始放置未能实现机械捕获，临床医生必须考虑几种潜在问题，并采用评估设备和纠正任何故障的方法。尽管在适当的患者中可以救命，但中央静脉通路、右心导管术和起搏线可能会导致并发症。
了解经静脉起搏器放置对急诊临床医生至关重要。
