Managing Pacemakers in the ED
A 67 year old male with a history of DM-2, HTN, HLD, CAD s/p MI with cath and ICD/pacemaker placement presents to the ED for evaluation of palpitations. The patient is visiting family and he forgot his ICD/pacemaker card at home. His wife does not recall the name of the ICD/pacemaker brand. You initiate a cardiac workup. You also call the cardiology EP fellow, who suggests identifying the pacemaker first before he can come down with the correct machine to interrogate the device.
There are over 1 million patients in the United States who have an ICD/pacemaker in place (Aguilera 2011). The scenario in this case (patient forgot his pacemaker card) is fairly common in many emergency departments receiving patients with cardiac PM/ICD who do not have their "mandatory carry at all times" card with them. It is unrealistic to expect a cardiologist/cardiology fellow to bring down all 5-10 different machines that are specific to each manufacturer (i.e. Medtronic, St. Jude, Boston Scientific, etc.). The machines are similar to ultrasound machines and cumbersome. The algorithm attached and in the links below is a useful way to figure out which pacemaker the patient has so that you can let the cardiologist/cardiology fellow know the brand.
Take Away #1:
It is important to know the brand of the pacemaker/ICD. Usually the patient has a card with the information. If the patient had a cath and pacemaker/ICD placement at your institution, look through the cath report for this information.
Take Away #2:
If the patient does not have the info card, use the algorithm here:
Alternatively, you can Google "Pacemaker CXR identification" and the first few results will have the algorithm. You can also take a picture of it with your phone or paste it in your department if space/leadership allows.
Take Away #3:
There is an App available for iOS and Android. You can take a picture of the pacemaker/ICD from your CXR. However, be careful with it, because errors have been noted.
You can confirm with the algorithm sheet. http://www.pacemakerid.com/
Cosmin Florescu, MD is a current third year resident at Stony Brook Emergency Medicine.
Aguilera, Amanda, Yulia V. Volokhina, and Kendra L. Fisher. Radiography of Cardiac Conduction Devices. A Comprehensive Review. RadioGraphics, Vol. 31, No. 6. Published online Oct 4, 2011. https://doi.org/10.1148/rg.316115529
Jacob, Sony et al. Cardiac Rhythm Device Identification Algorithm using X-Rays: CaRDIA-X. Available at https://www.ianchristoph.com/physician-resources-2/device_id.pdf [Accessed 18 November 2019]
Pacemaker ID App. Available for Web, iOS, and Android. http://www.pacemakerid.com/
Weingart, Scott. Which Pacemaker/ICD is that Again. EmCrit Blog. Published September 29, 2014. Available at https://emcrit.org/emcrit/which-pacemaker/ [Accessed 18 November 2019]
Weinreich, Michael et al. Computer-Aided Detection and Identification of Implanted Cardiac Devices on Chest Radiography Utilizing Deep Convolutional Neural Networks, A Form of Machine Learning. Journal of the American College of Cardiology. Volume 73, Issue 9, Supplement 1, March 2019.
Edited by Bassam Zahid, MD