CASE REPORT pacemaker, failure; trauma, blunt, pacemaker
Blunt T r a u m a - I n d u c e d P a c e m a k e r Failure A 54-year-old man with an artificial pacemaker sustained blunt trauma to his chest when he was struck with a baseball bat. Within 15 minutes after the injury, the patient experienced cardiovascular collapse. His pacemaker failed, and he required insertion of a temporary transvenous pacemaker. At surgery, the defect was traced to failure of the pulse generator, a rare cause of pacemaker failure. Emergency department evaluation should include prompt and continuous ECG monitoring, an overpenetrated chest radiograph, and telemetry evaluation after discharge. [Brown KR, Carter W Jr, Lombardi GE: Blunt trauma-induced pacemaker failure. Ann Emerg Med August 1991;20:905-907./
INTRODUCTION Pacemaker malfunction caused by trauma rarely occurs, but such a condition can be life threatening. In a patient who has sustained multiple trauma, failure to detect damage to the pacemaker may be as critical as inability to control hemorrhage. In this case report, failure of the pulse generator resulted from blunt trauma sustained after a baseball bat assault. The clinical signs arising from cessation of pacemaker activity, which include cardiovascular collapse and depressed mental state, must be differentiated from those due to hypovolemia and head injury. Prompt recognition and correct therapy must be instituted if pacemaker failure occurs after trauma.
Kevin R Brown, MD, MPH* Wallace Carter, Jr, MD* Gary E Lombardi, MD*t Bronx, New York From the Division of Emergency Medicine, Department of Ambulatory Care, Bronx Municipal Hospital Center; and Department of Medicine, Albert Einstein College of Medicine,t Bronx, New York. Received for publication December 4, 1990. Accepted for publication January 13, 1991. Address for reprints: Kevin Brown, MD, MPH, Department of Emergency Medicine, Bronx Municipal Hospital Center, Room Jacobi lW20, Bronx, New York 10461.
CASE REPORT A basic life support emergency medical services (EMS) crew responded to the assault on a M-year-old man. The patient was struck once in the chest by an assailant's baseball bat, fell to the ground, and sustained a chin laceration but maintained consciousness. When EMS personnel arrived, the patient was alert and oriented with full recall of the events relating to his injuries. During prophylactic cervical-spine immobilization, he became unresponsive, apneic, and pulseless. CPR was initiated, and the nearest Level I trauma center was alerted to stand by for a traumatic cardiac arrest. The initial emergency department evaluation revealed a middle-aged man with cyanotic skin and a stuporous mental state. His systolic blood pressure was 68 m m Hg by palpation; pulse, 25; and labored respirations, eight. The patient was orotracheally intubated with axial cervical traction. IV access and ECG monitoring were instituted. A total body survey revealed a 3-cm superficial submental laceration and a 4 x 20 cm contusion with swelling in the right infraclavicular region of the chest. On further inspection, the characteristic bulge of a permanent pacemaker was noted directly beneath the contused area. It was later determined that pacemaker implantation was necessitated 15 months earlier to treat symptomatic complete atrioventricular heart block. Telemetric evaluation of the unit three months before the incident had revealed proper function. During the initial minutes of resuscitation, vital signs remained unchanged, and the ECG revealed third-degree atrioventricular heart block with a ventrieular rate of 30 (Figure). No pacemaker spikes were observed. The ventricular rate was unresponsive to two IV doses of 0.5 mg atropine. An external transthoracic pacemaker was unavailable. A temporary trans-
124/905
Annals of Emergency Medicine
20:8 August 1991
PACEMAKER FAILURE Brown, Carter & Lombardi
FIGURE. Simultaneous three-lead
ECG rhythm tracing demonstrating third-degree atrioventricular heart block and abserlce of artificial pacer activity. venous pacemaker was introduced through the right internal jugular approach. Normal pacemaker capture with concurrent pulses was achieved. A chest radiograph revealed a bipolar pulse generator with a properly positioned electrode tip and no loss of continuity of the pacemaker wire. There was no pneumothorax, hemothorax, or fracture of the clavicle, sternum, or ribs. Within minutes of temporary pacemaker activation, the patient regained consciousness and had a pulse of 76 with a blood pressure of 130/80 mm Hg. Two days later, the defective p u l s e g e n e r a t o r ( m o d e l 283-01 COSMO type DDD, Intermedics Inc, Freeport, Texas) was removed surgically, and a new pulse generator was connected to the original pacemaker wires. Normal cardiac capture ensued, confirming that the pacemaker malfunction was limited to the pulse generator unit. The patient made an u n e v e n t f u l recovery and was discharged on hospital day 7. The hospital's biomedical department determined that the pulse generator had no electrical output. The device was delivered to the manufacturer, who confirmed the failure and identified the defect as a cracked ceramic substrate board that housed the electrical components. DISCUSSION Chest trauma is a seldom-recognized cause of pacemaker failure; there are 11 reported cases, b8 The majority of traumatic pacemaker failures are due to electrode displacement or wire fracture; only two were secondary to m a l f u n c t i o n of the pulse generator unit. 6,8 Pacemaker wire fracture has been reported in association with sudden abduction-hyperextension injuries of the upper extremity,~ carrying a heavy weight on the shoulder, 1 electrical shock, 2 sudden deceleration in a motor vehicle accident, 3 and blunt trauma to the chest caused by a lead pipe. 4 Displacement of the pacing electrode tip has occurred during vigorous activity involving sudden abduction and external rotation of the shoulder in three apple-pickers who 20:8 August 1991
grasped tree limbs to prevent falling, s during a boating accident that caused the patient to be thrown violently onto his back, 6 and in a high-speed motor vehicle accident when an unrestrained backseat passenger impacted the front seat. 7 The two cases of pulse generator failure occurred in patients involved in motor vehicle accidents. One incurred a steering wheel injury to the chest, 6 and the other was a pedestrian who was struck by an automobile, r e s u l t i n g in a dislocated shoulder. 8 The p a t i e n t w i t h the steering wheel injury did not exhibit pacemaker failure until the day after the accident, and subsequent analysis of the removed unit revealed a transistor failure. 6 Analysis of the pacemaker removed from the struck pedestrian revealed a leaky output capacitor. 8 Pulse generators are designed to be well insulated and resistant to injury mechanisms. The cracked ceramic baseboard in our patient has never been identified as a cause of pacemaker failure. In an unreported case, a victim of a gunshot wound to the chest experienced pacemaker failure due to d i s c o n n e c t i o n of the wire leads to the pulse generator, which was physically damaged by the bullet but f u n c t i o n a l l y i n t a c t (personal communication, R Reed, Public Relations, Medtronics Inc, 1990). The only other case of violence-associated pacemaker failure, 4 which also was reported by our institution, inAnnals of Emergency Medicine
volved a man who was attacked and severely beaten with a lead pipe, sustaining multiple fractures. Emergency medicine practitioners must be attuned to the life-threatening intrathoracic complications of blunt chest trauma; pacemaker failure, albeit rare, represents a potentially lethal consequence of such injuries. More t h a n 100,000 pacemakers are implanted each year in the United States, a and more than 2 million have been implanted in the past 25 years (R Reed, personal communication, 1990); therefore, a check for the presence of a pacemaker when dealing with victims of blunt chest trauma is important. Characteristic signs and symptoms of pacemaker failure may include a change in mental status, dizziness, palpitations, hypotension, a slow and/or irregular pulse, or sudden death. Patients with artificial pacemakers who sustain chest trauma should' have 12-lead ECG evaluation and continuous ECG monitoring. An overpenetrated chest radiograph is also helpful in identifying the type of pacemaker device as well as in detecting lead fracture and displacem e n t . 9,m Victims of b l u n t chest trauma who have permanent pacemakers and are treated and released should receive timely telemetric or Holter monitor follow-up.
SUMMARY A case of pacemaker malfunction due to failure of the pulse generator 906/125
PACEMAKER FAILURE Brown, Carter & Lombardi
component after blunt chest trauma is presented. Treatment of symptomatic patients requires implementation of temporary pacing techniques. A s y m p t o m a t i c patients with pacemakers who sustain chest trauma require ECG and/or telemetric monitoring because delayed failure also has been reported. REFERENCES t. Ohm OJ: Displacement and fracture of pacemaker
126/907
electrode during physical exertmn: Report on 3 cases Acta Med ScarM 1972;192:33-35.
6 M c C a n n WJ: P a c e m a k e r m a l f u n c t i o n associated in I~hmt traull"ta N Y ,Mat# ] Med 1989;78:64:,.
Tegtmeyer CL Bezirdjian DR, lrani FA, et al: Cardiac p a c e m a k e r failure: A c o m p l i c a t i o n of t r a u m a Sout]l M e d I 1981;74:378 379.
7 Lasky IL: Pacemaker failure froln atltOlnol~ilc accident (lctter}. lAMA 1970;211:170{l.
3. Griecc~ ]G, Scanhm Pl, IMarre R: Pacing lead fracture a f t e r a d e c e l e r a t i o n i n j u r y A n n T h l l r a c .Surt: 1989; 47:453 454. 4. Kmnzon I, M e h t a S: Broken pacemaker wire in mul tiple trauma: A case r e p o r t I Traulno 1974;14:82 8 4 5 Uppal SC, M o s t e r d WL: D i s ] o c a t i e van ceil pace maker-catheter bij her appels plukken. N e d e d Tijds~hr (,'etwesk 1973;117:295-296
Annals of Emergency Medicine
8 Gould L, Betzu R, Taddco M, L~t all: Pulse generator f a i [ u r e due to b l u n t t r a u m a (,!ill Cordi(d 1988;11: 581 582. 9 T c g t m e y e r CJ: R o e n t g e n o g r a p h i c a s s e s s m e n t /~f causes of cardiac pacemaker failure and cmnplications (2RC Clit t@~ (~]in Radio] Nu~/ Med 1977;9:t 5(). [0. Tcgtmcycr C]: Cmnplications ot cardiac pacemaker. A m FmrJ Phs', t976;14:66 7 5
20:8 August 1991
Blunt T r a u m a - I n d u c e d P a c e m a k e r Failure A 54-year-old man with an artificial pacemaker sustained blunt trauma to his chest when he was struck with a baseball bat. Within 15 minutes after the injury, the patient experienced cardiovascular collapse. His pacemaker failed, and he required insertion of a temporary transvenous pacemaker. At surgery, the defect was traced to failure of the pulse generator, a rare cause of pacemaker failure. Emergency department evaluation should include prompt and continuous ECG monitoring, an overpenetrated chest radiograph, and telemetry evaluation after discharge. [Brown KR, Carter W Jr, Lombardi GE: Blunt trauma-induced pacemaker failure. Ann Emerg Med August 1991;20:905-907./
INTRODUCTION Pacemaker malfunction caused by trauma rarely occurs, but such a condition can be life threatening. In a patient who has sustained multiple trauma, failure to detect damage to the pacemaker may be as critical as inability to control hemorrhage. In this case report, failure of the pulse generator resulted from blunt trauma sustained after a baseball bat assault. The clinical signs arising from cessation of pacemaker activity, which include cardiovascular collapse and depressed mental state, must be differentiated from those due to hypovolemia and head injury. Prompt recognition and correct therapy must be instituted if pacemaker failure occurs after trauma.
Kevin R Brown, MD, MPH* Wallace Carter, Jr, MD* Gary E Lombardi, MD*t Bronx, New York From the Division of Emergency Medicine, Department of Ambulatory Care, Bronx Municipal Hospital Center; and Department of Medicine, Albert Einstein College of Medicine,t Bronx, New York. Received for publication December 4, 1990. Accepted for publication January 13, 1991. Address for reprints: Kevin Brown, MD, MPH, Department of Emergency Medicine, Bronx Municipal Hospital Center, Room Jacobi lW20, Bronx, New York 10461.
CASE REPORT A basic life support emergency medical services (EMS) crew responded to the assault on a M-year-old man. The patient was struck once in the chest by an assailant's baseball bat, fell to the ground, and sustained a chin laceration but maintained consciousness. When EMS personnel arrived, the patient was alert and oriented with full recall of the events relating to his injuries. During prophylactic cervical-spine immobilization, he became unresponsive, apneic, and pulseless. CPR was initiated, and the nearest Level I trauma center was alerted to stand by for a traumatic cardiac arrest. The initial emergency department evaluation revealed a middle-aged man with cyanotic skin and a stuporous mental state. His systolic blood pressure was 68 m m Hg by palpation; pulse, 25; and labored respirations, eight. The patient was orotracheally intubated with axial cervical traction. IV access and ECG monitoring were instituted. A total body survey revealed a 3-cm superficial submental laceration and a 4 x 20 cm contusion with swelling in the right infraclavicular region of the chest. On further inspection, the characteristic bulge of a permanent pacemaker was noted directly beneath the contused area. It was later determined that pacemaker implantation was necessitated 15 months earlier to treat symptomatic complete atrioventricular heart block. Telemetric evaluation of the unit three months before the incident had revealed proper function. During the initial minutes of resuscitation, vital signs remained unchanged, and the ECG revealed third-degree atrioventricular heart block with a ventrieular rate of 30 (Figure). No pacemaker spikes were observed. The ventricular rate was unresponsive to two IV doses of 0.5 mg atropine. An external transthoracic pacemaker was unavailable. A temporary trans-
124/905
Annals of Emergency Medicine
20:8 August 1991
PACEMAKER FAILURE Brown, Carter & Lombardi
FIGURE. Simultaneous three-lead
ECG rhythm tracing demonstrating third-degree atrioventricular heart block and abserlce of artificial pacer activity. venous pacemaker was introduced through the right internal jugular approach. Normal pacemaker capture with concurrent pulses was achieved. A chest radiograph revealed a bipolar pulse generator with a properly positioned electrode tip and no loss of continuity of the pacemaker wire. There was no pneumothorax, hemothorax, or fracture of the clavicle, sternum, or ribs. Within minutes of temporary pacemaker activation, the patient regained consciousness and had a pulse of 76 with a blood pressure of 130/80 mm Hg. Two days later, the defective p u l s e g e n e r a t o r ( m o d e l 283-01 COSMO type DDD, Intermedics Inc, Freeport, Texas) was removed surgically, and a new pulse generator was connected to the original pacemaker wires. Normal cardiac capture ensued, confirming that the pacemaker malfunction was limited to the pulse generator unit. The patient made an u n e v e n t f u l recovery and was discharged on hospital day 7. The hospital's biomedical department determined that the pulse generator had no electrical output. The device was delivered to the manufacturer, who confirmed the failure and identified the defect as a cracked ceramic substrate board that housed the electrical components. DISCUSSION Chest trauma is a seldom-recognized cause of pacemaker failure; there are 11 reported cases, b8 The majority of traumatic pacemaker failures are due to electrode displacement or wire fracture; only two were secondary to m a l f u n c t i o n of the pulse generator unit. 6,8 Pacemaker wire fracture has been reported in association with sudden abduction-hyperextension injuries of the upper extremity,~ carrying a heavy weight on the shoulder, 1 electrical shock, 2 sudden deceleration in a motor vehicle accident, 3 and blunt trauma to the chest caused by a lead pipe. 4 Displacement of the pacing electrode tip has occurred during vigorous activity involving sudden abduction and external rotation of the shoulder in three apple-pickers who 20:8 August 1991
grasped tree limbs to prevent falling, s during a boating accident that caused the patient to be thrown violently onto his back, 6 and in a high-speed motor vehicle accident when an unrestrained backseat passenger impacted the front seat. 7 The two cases of pulse generator failure occurred in patients involved in motor vehicle accidents. One incurred a steering wheel injury to the chest, 6 and the other was a pedestrian who was struck by an automobile, r e s u l t i n g in a dislocated shoulder. 8 The p a t i e n t w i t h the steering wheel injury did not exhibit pacemaker failure until the day after the accident, and subsequent analysis of the removed unit revealed a transistor failure. 6 Analysis of the pacemaker removed from the struck pedestrian revealed a leaky output capacitor. 8 Pulse generators are designed to be well insulated and resistant to injury mechanisms. The cracked ceramic baseboard in our patient has never been identified as a cause of pacemaker failure. In an unreported case, a victim of a gunshot wound to the chest experienced pacemaker failure due to d i s c o n n e c t i o n of the wire leads to the pulse generator, which was physically damaged by the bullet but f u n c t i o n a l l y i n t a c t (personal communication, R Reed, Public Relations, Medtronics Inc, 1990). The only other case of violence-associated pacemaker failure, 4 which also was reported by our institution, inAnnals of Emergency Medicine
volved a man who was attacked and severely beaten with a lead pipe, sustaining multiple fractures. Emergency medicine practitioners must be attuned to the life-threatening intrathoracic complications of blunt chest trauma; pacemaker failure, albeit rare, represents a potentially lethal consequence of such injuries. More t h a n 100,000 pacemakers are implanted each year in the United States, a and more than 2 million have been implanted in the past 25 years (R Reed, personal communication, 1990); therefore, a check for the presence of a pacemaker when dealing with victims of blunt chest trauma is important. Characteristic signs and symptoms of pacemaker failure may include a change in mental status, dizziness, palpitations, hypotension, a slow and/or irregular pulse, or sudden death. Patients with artificial pacemakers who sustain chest trauma should' have 12-lead ECG evaluation and continuous ECG monitoring. An overpenetrated chest radiograph is also helpful in identifying the type of pacemaker device as well as in detecting lead fracture and displacem e n t . 9,m Victims of b l u n t chest trauma who have permanent pacemakers and are treated and released should receive timely telemetric or Holter monitor follow-up.
SUMMARY A case of pacemaker malfunction due to failure of the pulse generator 906/125
PACEMAKER FAILURE Brown, Carter & Lombardi
component after blunt chest trauma is presented. Treatment of symptomatic patients requires implementation of temporary pacing techniques. A s y m p t o m a t i c patients with pacemakers who sustain chest trauma require ECG and/or telemetric monitoring because delayed failure also has been reported. REFERENCES t. Ohm OJ: Displacement and fracture of pacemaker
126/907
electrode during physical exertmn: Report on 3 cases Acta Med ScarM 1972;192:33-35.
6 M c C a n n WJ: P a c e m a k e r m a l f u n c t i o n associated in I~hmt traull"ta N Y ,Mat# ] Med 1989;78:64:,.
Tegtmeyer CL Bezirdjian DR, lrani FA, et al: Cardiac p a c e m a k e r failure: A c o m p l i c a t i o n of t r a u m a Sout]l M e d I 1981;74:378 379.
7 Lasky IL: Pacemaker failure froln atltOlnol~ilc accident (lctter}. lAMA 1970;211:170{l.
3. Griecc~ ]G, Scanhm Pl, IMarre R: Pacing lead fracture a f t e r a d e c e l e r a t i o n i n j u r y A n n T h l l r a c .Surt: 1989; 47:453 454. 4. Kmnzon I, M e h t a S: Broken pacemaker wire in mul tiple trauma: A case r e p o r t I Traulno 1974;14:82 8 4 5 Uppal SC, M o s t e r d WL: D i s ] o c a t i e van ceil pace maker-catheter bij her appels plukken. N e d e d Tijds~hr (,'etwesk 1973;117:295-296
Annals of Emergency Medicine
8 Gould L, Betzu R, Taddco M, L~t all: Pulse generator f a i [ u r e due to b l u n t t r a u m a (,!ill Cordi(d 1988;11: 581 582. 9 T c g t m e y e r CJ: R o e n t g e n o g r a p h i c a s s e s s m e n t /~f causes of cardiac pacemaker failure and cmnplications (2RC Clit t@~ (~]in Radio] Nu~/ Med 1977;9:t 5(). [0. Tcgtmcycr C]: Cmnplications ot cardiac pacemaker. A m FmrJ Phs', t976;14:66 7 5
20:8 August 1991
