One day on rounds I examined a elderly individual who had presented late with a inferior MI and was on Dabigatrin anti coagulation for chronic atrial fibrillation. He had not called for help because he awoke in the middle of the night with chest pain. He presented the next morning pain free and was not given thrombolytics. I was latter summoned to the CCU to find him in atrial fibrillation at a rate of 20-40 min on Isoproternol drip he was hypotensive and hypo perfused looking a dusky blue.
We initiated external pacing which worked but was very painful. As I called for emergency fluoroscopy to help place a temporary pacemaker I worried about the risk of a bleeding complication in obtaining central venous access in this anti coagulated patient. The preferred route of access for temporary trans venous pacing is the right internal jugular vein followed by the subclavian and femoral veins*. However to my relief the patient had a large right external jugular vein which would allow venous access without the danger of arterial puncture. I was able to quickly cannulate the right external jugular vein and with fluoroscopy guidance place a temporary wire into the right ventricle and successfully paced the patient. With pacing his blood pressure returned to normal and a pink color returned to his face. He received a permanent pacemaker the next day and was able to walk out of the hospital the following week.
We initiated external pacing which worked but was very painful. As I called for emergency fluoroscopy to help place a temporary pacemaker I worried about the risk of a bleeding complication in obtaining central venous access in this anti coagulated patient. The preferred route of access for temporary trans venous pacing is the right internal jugular vein followed by the subclavian and femoral veins*. However to my relief the patient had a large right external jugular vein which would allow venous access without the danger of arterial puncture. I was able to quickly cannulate the right external jugular vein and with fluoroscopy guidance place a temporary wire into the right ventricle and successfully paced the patient. With pacing his blood pressure returned to normal and a pink color returned to his face. He received a permanent pacemaker the next day and was able to walk out of the hospital the following week.
- *The preferred route of access for temporary transvenous pacing is the internal jugular vein followed by subclavian and femoral veins. However, all the major venous access sites (internal and external jugular, subclavian, brachial, femoral) have been used and each is associated with particular problems
- The right-sided veins should be used when possible.
