Clinical Assessment and Pacemaker Trouble-shooting: Evaluation of Possible Pacing Problems in the ED

Pacemaker problems may be implicated in a wide variety of patient presentations to the ED. It is best to approach these in a systematic way, and try to answer the following points if at all possible:

  1. What device is implanted, and when?
  2. How is the device set up, in terms of mode and rate etc.?
  3. What is the patient’s own intrinsic rhythm and rate?
  4. Is there evidence of appropriate pacing activity on the surface ECG?
  5. Is there evidence of appropriate sensing on the surface ECG?
  6. If no to 4 and 5, is there evidence of inappropriate pacing/sensing?
  7. Is there any evidence of a mechanical complication, i.e., lead displacement, fracture etc.?
  8. Is there evidence of a local complication such as infection or erosion?

Answering these questions may be difficult at first presentation in the ED, but useful information can be gathered from the history, clinical examination, surface ECG, chest x-ray and blood tests.