Failure of communication and capture: The perils of temporary unipolar pacing system.
We present a case of a patient with pacemaker dependence secondary to complete heart block who developed loss of capture of her temporary pacemaker. Patient developed torsades de pointes then ventricular fibrillation, requiring CPR and external cardioversion. After patient was stabilized, it was noticed that loss of capture of pacemaker corresponded with nursing care, when the pulse generator was lifted off patient׳s chest wall, and that patient׳s temporary pacing system had been programmed to unipolar mode without knowledge of attending cardiologist. This case highlights the importance of communication ensuring all caregivers are aware of mode of the temporary pacing system.
University of Alabama (UAB) School of Medicine, VH 227, 1530 3rd Ave S Birmingham, AL 35294, United States.
Efe
E
Sahinoglu
Department of Cardiology, Baptist Medical Center South, United States.
Thomas J
TJ
Wool
Department of Cardiology, Baptist Medical Center South, United States ; Department of Internal Medicine, UAB Montgomery, United States.
Kenneth J
KJ
Wool
Biventricular pacing/defibrillation; Conduction disturbances; Lead implantation/extraction; Ventricular fibrillation