Pacemaker and Icd Related PresentationsAPPROACH

CHEST AND CARDIOVASCULAR · 19 SECTIONS

⚲

487 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Pacemaker And Icd Related Presentations Acute Limb Ischemia And Leg Pain Suspected Deep Vein Thrombosis Symptoms Hypertension Chest Pain Palpitations And Tachyarrhythmia Symptoms Bradycardia Symptoms Syncope And Presyncope Syncope With Neurologic Concern Unilateral Leg Swelling Bilateral Leg Swelling Calf Pain And Swelling

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx73

Presenting symptoms

›Symptom characterization

›Syncope or presyncope with implanted device

›Palpitations or perceived arrhythmia

›Dyspnea or exercise intolerance

›Chest pain

›ICD shock or vibration alert

›Dizziness or near falls

›Weakness or fatigue

›Device pocket pain or swelling

›Fever or rigors with device

Device history

›Device details

›Pacemaker

›ICD

›CRT pacemaker

›CRT defibrillator

›Implant date and indication

›Recent generator change

›Recent lead revision

›Recent ablation or cardiac surgery

›Manufacturer and model if known

OPQRST

›Symptom timeline

›Onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Exertion related

›Position related

›Vagal trigger

›Relief with rest

›Quality

›Lightheadedness

›Palpitations

›Chest pressure

›Dyspnea sensation

›Region and radiation

›Chest discomfort location

›Radiation to jaw

›Radiation to arm

›Pocket discomfort location

›Severity

›Near syncope

›Complete loss of consciousness

›Multiple ICD shocks

›Timing

›Constant symptoms

›Intermittent episodes

›Clustered events

Associated symptoms

›Associated symptoms

›Diaphoresis

›Nausea or vomiting

›Neurologic deficit symptoms

›Fever

›Chills

›Orthopnea

›Pleuritic pain

›Hemoptysis

›Pocket drainage

ICD shock details

›Shock event characterization

›Single shock

›Multiple shocks

›Shocks at rest

›Shocks with activity

›Prodrome before shock

›Loss of consciousness with shock

›Chest pain after shock

›Device audible alert history

Exposures and triggers

›Trigger review

›Recent strong electromagnetic exposure

›TENS unit exposure

›Electrocautery exposure

›High voltage work exposure

›MRI exposure

›Recent falls or chest trauma

02Alarm Features/alarm33

Immediate threats

›Life threat triggers

›Hemodynamic instability

›Ongoing chest pain with ischemic features

›Ventricular tachycardia or ventricular fibrillation

›Recurrent ICD shocks

›Symptomatic bradycardia with hypoperfusion

›Suspected cardiac tamponade

›Suspected device infection with sepsis

Vital sign danger thresholds

›Vital thresholds

›Systolic blood pressure less than 90 mmHg with symptoms

›Oxygen saturation less than 90 percent on room air

›Heart rate less than 40 per minute with symptoms

›Sustained heart rate greater than 150 per minute with symptoms

›Temperature 38.0 C or higher with device pocket concerns

High risk exam findings

›Exam red flags

›Altered mental status

›New focal neurologic deficit

›Jugular venous distension with hypotension

›New muffled heart sounds

›Rapidly expanding pocket hematoma

›Purulent pocket drainage

›Crepitus at pocket

High risk device specific patterns

›Device red flags

›Electrical storm

›Incessant ventricular arrhythmia despite therapy

›Pacer dependency with suspected malfunction

›Failure to capture with symptomatic bradycardia

›Inappropriate shocks with distress

Escalation logic

›Escalation

›If unstable tachyarrhythmia, synchronized cardioversion

›If pulseless, defibrillation and cardiac arrest algorithm

›If suspected tamponade, immediate bedside ultrasound and cardiology involvement

›If suspected device infection with sepsis physiology, early broad spectrum antibiotics and urgent specialty consultation

03Medications/meds29

Home medications relevant to device presentations

›Medication reconciliation

›Beta blocker

›Non dihydropyridine calcium channel blocker

›Amiodarone

›Sotalol

›Dofetilide

›Digoxin

›Diuretic

›ACE inhibitor or ARB

›Sacubitril valsartan

›SGLT2 inhibitor

Antithrombotics

›Antithrombotic review

›Aspirin

›P2Y12 inhibitor

›Warfarin

›Direct oral anticoagulant

›Recent missed doses

›Recent supratherapeutic anticoagulation concern

Pro arrhythmic and interaction risks

›QT and interaction risks

›Recent QT prolonging antibiotics

›Antipsychotic exposure

›Antiemetic QT prolongation risk

›Stimulant exposure

›Thyroid medication dose change

ED medications with device context

›ED medication safety

›Adenosine caution in irregular wide complex tachycardia

›AV nodal blockers caution in preexcited atrial fibrillation

›Amiodarone infusion protocol dependent

›Procainamide dosing protocol dependent

04Diet/diet7

Intake patterns affecting arrhythmia and thresholds

›Diet and hydration

›Poor oral intake

›Dehydration symptoms

›High caffeine intake

›Energy drink intake

›High sodium intake in heart failure

›Recent vomiting or diarrhea

05Review of Systems/ros20

Cardiopulmonary

›Cardiopulmonary symptoms

›Exertional dyspnea

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Leg swelling

›Chest pressure

›Pleuritic pain

›Palpitations

Infectious and inflammatory

›Infectious symptoms

›Fever

›Chills

›Night sweats

›Unintentional weight loss

›Pocket redness progression

Neurologic

›Neurologic symptoms

›Headache

›Focal weakness

›Speech difficulty

›Seizure like activity

›Post event confusion

06Collateral History and Family History/chafh14

Collateral sources

›Collateral

›Witness description of syncope

›EMS rhythm strips if available

›Device clinic notes if available

›Prior device interrogation reports

Family history

›Family history

›Sudden cardiac death

›Cardiomyopathy

›Channelopathy

›Early coronary artery disease

Social reliability

›Support and follow up reliability

›Ability to attend urgent device clinic follow up

›Medication access

›Home monitoring presence

07Risk Factors/rf26

Device and procedure risks

›Device related risks

›Recent implantation less than 6 weeks

›Recent generator change

›Multiple prior leads

›Prior device infection

›Pacer dependent status

›Known lead recall or advisory

Arrhythmia and cardiac risks

›Cardiac risks

›Ischemic cardiomyopathy

›Non ischemic cardiomyopathy

›Prior ventricular tachycardia

›Prior atrial fibrillation

›Heart failure reduced ejection fraction

›Structural heart disease

Infection and bleeding risks

›Infection and bleeding risks

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Immunosuppression

›Anticoagulation

›Antiplatelet therapy

›Hematoma after implant history

Exposure risks

›Electromagnetic and toxin risks

›Stimulant use

›Cocaine or sympathomimetic exposure

›Carbon monoxide exposure possibility

›Significant electromagnetic interference exposure

08Differential Diagnosis/ddx64

Life threatening

›Life threatening causes

›Ventricular tachycardia (I47.2)

›Shock syncope correlation

›Wide complex tachycardia on ECG

›Ventricular fibrillation (I49.01)

›Cardiac arrest history

›Multiple ICD therapies

›Acute coronary syndrome (I21.9)

›New ischemic ECG changes

›Rising troponin pattern

›Pacemaker failure in pacer dependent patient (T82.110A)

›Failure to capture on ECG

›Profound bradycardia

›Cardiac tamponade from lead perforation (I31.4)

›Hypotension with jugular venous distension

›Pericardial effusion on ultrasound

›Pulmonary embolism (I26.99)

›Hypoxia with tachycardia

›Pleuritic pain or hemoptysis

›CIED infection with bacteremia or endocarditis (T82.7XXA)

›Fever with pocket changes

›Positive blood cultures

Common

›Common causes

›Inappropriate ICD shock from supraventricular tachycardia

›Narrow complex tachycardia history

›Shock during exertion with palpitations

›Atrial fibrillation with rapid ventricular response (I48.91)

›Irregularly irregular rhythm

›Rate related symptoms

›Lead fracture or insulation failure (T82.110A)

›Intermittent sensing abnormalities

›Noise on interrogation history

›Pacemaker mediated tachycardia

›Regular tachycardia near upper tracking rate

›Retrograde P waves pattern on ECG

›Battery depletion elective replacement indicator

›Change in pacing mode

›New bradycardia or fatigue

›Vasovagal syncope (R55)

›Typical prodrome

›Normal device function on interrogation

Less common

›Less common causes

›Twiddler syndrome with lead displacement (T82.120A)

›Pocket manipulation history

›Change in lead position on chest radiograph

›Oversensing from electromagnetic interference

›Symptom timing near exposure

›Inhibition of pacing on ECG pattern

›Myocarditis (I40.9)

›Viral prodrome

›Troponin elevation with non ischemic ECG

›Electrolyte mediated arrhythmia

›Hypokalemia

›Hypomagnesemia

Mimics and non cardiac

›Mimics

›Seizure

›Tongue bite history

›Post event confusion

›Orthostatic hypotension

›Volume depletion history

›Postural symptom pattern

›Anxiety or panic

›Normal rhythm during symptoms

›Reassuring cardiopulmonary evaluation

09Past Medical History/pmh18

Cardiac history

›Cardiac history

›Indication for device

›Prior myocardial infarction

›Prior revascularization

›Heart failure stage and baseline symptoms

›Prior arrhythmia ablation

›Baseline ejection fraction

Device and procedural history

›Device history

›Prior lead extraction

›Prior pocket revision

›Prior device infection

›Device advisory or recall history

Other relevant history

›Comorbidities

›Chronic kidney disease

›Diabetes mellitus

›COPD

›Obstructive sleep apnea

›Thyroid disease

10Physical Exam/exam33

General and hemodynamics

›General assessment

›Toxic appearance

›Perfusion assessment

›Mental status

›Volume status

Cardiovascular

›Cardiovascular exam

›Rate and rhythm assessment

›Murmur new or changed

›Jugular venous distension

›Peripheral edema

›Signs of tamponade physiology

Respiratory

›Respiratory exam

›Work of breathing

›Crackles

›Wheeze

›Asymmetric breath sounds

Device pocket and leads

›Pocket exam

›Erythema

›Warmth

›Fluctuance

›Drainage

›Skin erosion

›Tenderness

›Hematoma size and tension

Neurologic and trauma

›Neuro and trauma screen

›Focal neurologic deficit

›Postictal features

›Head or facial trauma from syncope

›Cervical spine pain after fall

Special populations considerations

›Special populations exam

›Pregnancy uterine size considerations for imaging decisions

›Pediatric device location and growth related lead strain

›Anticoagulated patient bruising and pocket bleeding

11Lab Studies/labs20

Core ED labs

›Baseline labs

›CBC for anemia and leukocytosis

›Electrolytes including potassium

›Magnesium level

›Creatinine and renal function

›Glucose

Cardiac and ischemia evaluation

›Cardiac labs

›Troponin trend when ischemia concern

›BNP or NT proBNP when heart failure concern

Infection evaluation

›Infection labs

›Blood cultures times two if fever or pocket infection concern

›Lactate when sepsis physiology

›CRP or ESR as supportive data when unclear

Toxicology and endocrine

›Additional labs

›TSH when new arrhythmia or amiodarone exposure concern

›Toxicology testing when stimulant exposure concern

Lab interpretation pitfalls

›Pitfalls

›Mild troponin elevation after ICD shocks possible

›Electrolyte abnormalities can trigger shocks and arrhythmias

›Fever absent in early device infection

12Imaging/img19

Scoring Systems

›Decision tools

›Syncope risk stratification tool local protocol dependent

›Pulmonary embolism pretest probability tool when PE concern

›Sepsis screening criteria for infection physiology

MRI

›MRI considerations

›MRI conditional device status required before MRI

›Device and lead compatibility required

›Coordination with device team for mode programming

›Non conditional system treated as high risk without specialist protocol

›CT considerations

›CT pulmonary angiography when PE concern and appropriate renal function

›CT head when syncope with head trauma or focal neurologic findings

›Contrast nephropathy risk in CKD

›Radiation consideration in pregnancy and pediatrics

Ultrasound

›Ultrasound and POCUS

›Bedside echocardiography for pericardial effusion

›Lung ultrasound for pulmonary edema

›IVC assessment as adjunct to volume status

›Venous ultrasound for DVT when PE pathway considered

13Special Tests/spec18

Device interrogation and related diagnostics

›Device evaluation

›Urgent device interrogation for shocks or suspected malfunction

›Review of stored electrograms if available

›Battery status including elective replacement indicator

›Lead parameters sensing impedance thresholds

Chest radiograph evaluation

›Chest radiograph

›Lead position assessment compared with prior

›Lead fracture clues

›Generator position and rotation clues

Magnet response testing

›Magnet use

›Magnet effect differs by manufacturer and programming

›Pacemaker magnet typically asynchronous pacing while applied

›ICD magnet typically disables tachy therapies while applied

›Use only with monitoring and specialist input when feasible

Bedside maneuvers and monitoring

›Bedside diagnostics

›Orthostatic vitals when appropriate

›Continuous telemetry for suspected arrhythmia

›Serial neurologic checks after syncope related trauma

14ECG/ecg24

Immediate ECG priorities

›ECG triage

›12 lead ECG early for syncope or shock presentation

›Rhythm strip and telemetry correlation with symptoms

Paced rhythm interpretation

›Paced ECG interpretation

›Atrial paced spikes with P wave capture

›Ventricular paced spikes with wide QRS morphology

›Biventricular pacing pattern for CRT

›Pacing rate compared with programmed lower rate if known

Malfunction patterns

›Malfunction ECG patterns

›Failure to pace with absent pacing spikes when expected

›Failure to capture with spikes not followed by depolarization

›Undersensing with inappropriate pacing spikes

›Oversensing with inappropriate inhibition of pacing

Tachyarrhythmia patterns relevant to devices

›Tachyarrhythmias

›Monomorphic wide complex tachycardia treated as ventricular tachycardia until proven otherwise

›Polymorphic wide complex tachycardia with QT prolongation concern

›Atrial fibrillation with rapid ventricular response

›Supraventricular tachycardia triggers for inappropriate ICD therapy

High risk ECG findings

›ECG red flags

›Ischemic ST elevation or depression

›New high grade AV block

›Hyperkalemia ECG features

›Brugada pattern concern

›Preexcited atrial fibrillation concern

15Assessment/ax21

Problem representation

›Working problem list

›ICD shock presentation with stability assessment

›Syncope in patient with pacemaker or ICD

›Suspected pacemaker malfunction

›Suspected device pocket infection

›Suspected lead complication after recent implant

Severity stratification

›Severity stratification

›Unstable physiology requiring resuscitation bay

›Electrical storm suspicion with recurrent therapies

›Pacer dependent risk with suspected capture failure

›Sepsis physiology with device infection concern

Key complications to rule out

›Complication screen

›Acute coronary syndrome

›Heart failure decompensation

›Pulmonary embolism

›Pericardial effusion and tamponade

›Stroke or TIA after syncope or arrhythmia

Diagnostic uncertainty handling

›Uncertainty

›If symptoms but normal ECG and stable, prioritize device interrogation and ambulatory rhythm correlation

›If pocket findings equivocal, prioritize blood cultures and specialist input

›If intermittent symptoms, prioritize telemetry observation pathway when risk factors present

16Plan/plan29

First minutes stabilization

›Initial stabilization

›Cardiac monitor and defibrillator pads for shock presentations

›IV access and basic labs

›Oxygen for hypoxia

›Treat unstable arrhythmia per ACLS algorithms

ICD shock management

›ICD shock plan

›If unstable ventricular tachycardia, synchronized cardioversion

›If ventricular fibrillation or pulseless ventricular tachycardia, defibrillation

›If electrical storm with stability, antiarrhythmic infusion protocol dependent

›If recurrent shocks with distress and suspected inappropriate therapy, consider magnet to suspend tachy therapies with continuous monitoring and urgent cardiology involvement

Pacemaker malfunction management

›Pacemaker malfunction plan

›If symptomatic bradycardia with capture failure, transcutaneous pacing and escalation

›If pacer dependent and suspected malfunction, urgent device interrogation and cardiology

›Correct reversible causes including electrolytes and ischemia

›Avoid external electrical interference sources when identified

Pocket hematoma and bleeding

›Pocket bleeding plan

›Analgesia and local measures

›Anticoagulation management local protocol dependent

›Rapidly expanding hematoma requires urgent specialty input

Infection and endocarditis pathway

›Infection plan

›Blood cultures times two before antibiotics when feasible

›Broad spectrum antibiotics for sepsis physiology local protocol dependent

›Echocardiography pathway when bacteremia or endocarditis concern

›Early electrophysiology and infectious disease involvement for suspected CIED infection

Reassessment loop

›Reassessment

›Repeat vitals and symptom check after interventions

›Repeat ECG with symptom changes

›Telemetry review for recurrent arrhythmia

›Escalate level of care if instability develops

17Disposition/dispo25

ICU criteria

›ICU criteria

›Electrical storm

›Recurrent ventricular arrhythmia requiring continuous antiarrhythmic infusion

›Hemodynamic instability

›Suspected tamponade physiology

›Sepsis requiring vasopressors

Inpatient admission criteria

›Admission criteria

›Appropriate ICD shocks for ventricular arrhythmia

›New device malfunction affecting safety

›Pacer dependency with any suspicion of malfunction

›Suspected device infection

›Syncope with high risk ECG findings

Observation pathway criteria

›Observation criteria

›Stable single shock with unclear appropriateness pending interrogation

›Stable palpitations with device and need for telemetry correlation

›Syncope with intermediate risk features and planned urgent interrogation

Discharge criteria

›Discharge criteria

›Stable vitals with reassuring evaluation

›Device interrogation reassuring with clear explanation of symptoms

›No concerning pocket findings

›Reliable rapid follow up with device clinic

Follow up timing

›Follow up plan

›Device clinic follow up within 24 to 72 hours for recent shock or alerts

›Cardiology follow up within 1 week for medication changes

›Primary care follow up for contributing factors

18Discharge Instructions/di7

Copy discharge instructions

›Discharge text

›You were evaluated for symptoms in the setting of an implanted cardiac device

›Return immediately for fainting, chest pain, trouble breathing, repeated shocks, fever, or worsening pocket redness or drainage

›Avoid strong electromagnetic sources near your device and keep phones and magnets away from the implant site

›Take your medications as prescribed and do not stop heart rhythm medicines without medical advice

›Arrange urgent follow up with your device clinic as directed

›If you received an ICD shock today, do not drive until cleared by your clinician local protocol dependent

19References/r7

Guidelines and key sources

›Reference list

›AHA Guidelines for CPR and ECC 2020

›ESC Guidelines on cardiac pacing and cardiac resynchronization therapy 2021

›HRS Expert Consensus Statement on cardiovascular implantable electronic device lead management and extraction 2017

›MADIT II trial 2002

›SCD HeFT trial 2005

›Project instructions

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Pacemaker and Icd Related PresentationsAPPROACH

CHEST AND CARDIOVASCULAR · 19 SECTIONS

⚲

487 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx73

Presenting symptoms

›Symptom characterization

›Syncope or presyncope with implanted device

›Palpitations or perceived arrhythmia

›Dyspnea or exercise intolerance

›Chest pain

›ICD shock or vibration alert

›Dizziness or near falls

›Weakness or fatigue

›Device pocket pain or swelling

›Fever or rigors with device

Device history

›Device details

›Pacemaker

›ICD

›CRT pacemaker

›CRT defibrillator

›Implant date and indication

›Recent generator change

›Recent lead revision

›Recent ablation or cardiac surgery

›Manufacturer and model if known

OPQRST

›Symptom timeline

›Onset

›Sudden onset

›Gradual onset

›Provocation and palliation

›Exertion related

›Position related

›Vagal trigger

›Relief with rest

›Quality

›Lightheadedness

›Palpitations

›Chest pressure

›Dyspnea sensation

›Region and radiation

›Chest discomfort location

›Radiation to jaw

›Radiation to arm

›Pocket discomfort location

›Severity

›Near syncope

›Complete loss of consciousness

›Multiple ICD shocks

›Timing

›Constant symptoms

›Intermittent episodes

›Clustered events

Associated symptoms

›Associated symptoms

›Diaphoresis

›Nausea or vomiting

›Neurologic deficit symptoms

›Fever

›Chills

›Orthopnea

›Pleuritic pain

›Hemoptysis

›Pocket drainage

ICD shock details

›Shock event characterization

›Single shock

›Multiple shocks

›Shocks at rest

›Shocks with activity

›Prodrome before shock

›Loss of consciousness with shock

›Chest pain after shock

›Device audible alert history

Exposures and triggers

›Trigger review

›Recent strong electromagnetic exposure

›TENS unit exposure

›Electrocautery exposure

›High voltage work exposure

›MRI exposure

›Recent falls or chest trauma

02Alarm Features/alarm33

Immediate threats

›Life threat triggers

›Hemodynamic instability

›Ongoing chest pain with ischemic features

›Ventricular tachycardia or ventricular fibrillation

›Recurrent ICD shocks

›Symptomatic bradycardia with hypoperfusion

›Suspected cardiac tamponade

›Suspected device infection with sepsis

Vital sign danger thresholds

›Vital thresholds

›Systolic blood pressure less than 90 mmHg with symptoms

›Oxygen saturation less than 90 percent on room air

›Heart rate less than 40 per minute with symptoms

›Sustained heart rate greater than 150 per minute with symptoms

›Temperature 38.0 C or higher with device pocket concerns

High risk exam findings

›Exam red flags

›Altered mental status

›New focal neurologic deficit

›Jugular venous distension with hypotension

›New muffled heart sounds

›Rapidly expanding pocket hematoma

›Purulent pocket drainage

›Crepitus at pocket

High risk device specific patterns

›Device red flags

›Electrical storm

›Incessant ventricular arrhythmia despite therapy

›Pacer dependency with suspected malfunction

›Failure to capture with symptomatic bradycardia

›Inappropriate shocks with distress

Escalation logic

›Escalation

›If unstable tachyarrhythmia, synchronized cardioversion

›If pulseless, defibrillation and cardiac arrest algorithm

›If suspected tamponade, immediate bedside ultrasound and cardiology involvement

›If suspected device infection with sepsis physiology, early broad spectrum antibiotics and urgent specialty consultation

03Medications/meds29

Home medications relevant to device presentations

›Medication reconciliation

›Beta blocker

›Non dihydropyridine calcium channel blocker

›Amiodarone

›Sotalol

›Dofetilide

›Digoxin

›Diuretic

›ACE inhibitor or ARB

›Sacubitril valsartan

›SGLT2 inhibitor

Antithrombotics

›Antithrombotic review

›Aspirin

›P2Y12 inhibitor

›Warfarin

›Direct oral anticoagulant

›Recent missed doses

›Recent supratherapeutic anticoagulation concern

Pro arrhythmic and interaction risks

›QT and interaction risks

›Recent QT prolonging antibiotics

›Antipsychotic exposure

›Antiemetic QT prolongation risk

›Stimulant exposure

›Thyroid medication dose change

ED medications with device context

›ED medication safety

›Adenosine caution in irregular wide complex tachycardia

›AV nodal blockers caution in preexcited atrial fibrillation

›Amiodarone infusion protocol dependent

›Procainamide dosing protocol dependent

04Diet/diet7

Intake patterns affecting arrhythmia and thresholds

›Diet and hydration

›Poor oral intake

›Dehydration symptoms

›High caffeine intake

›Energy drink intake

›High sodium intake in heart failure

›Recent vomiting or diarrhea

05Review of Systems/ros20

Cardiopulmonary

›Cardiopulmonary symptoms

›Exertional dyspnea

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Leg swelling

›Chest pressure

›Pleuritic pain

›Palpitations

Infectious and inflammatory

›Infectious symptoms

›Fever

›Chills

›Night sweats

›Unintentional weight loss

›Pocket redness progression

Neurologic

›Neurologic symptoms

›Headache

›Focal weakness

›Speech difficulty

›Seizure like activity

›Post event confusion

06Collateral History and Family History/chafh14

Collateral sources

›Collateral

›Witness description of syncope

›EMS rhythm strips if available

›Device clinic notes if available

›Prior device interrogation reports

Family history

›Family history

›Sudden cardiac death

›Cardiomyopathy

›Channelopathy

›Early coronary artery disease

Social reliability

›Support and follow up reliability

›Ability to attend urgent device clinic follow up

›Medication access

›Home monitoring presence

07Risk Factors/rf26

Device and procedure risks

›Device related risks

›Recent implantation less than 6 weeks

›Recent generator change

›Multiple prior leads

›Prior device infection

›Pacer dependent status

›Known lead recall or advisory

Arrhythmia and cardiac risks

›Cardiac risks

›Ischemic cardiomyopathy

›Non ischemic cardiomyopathy

›Prior ventricular tachycardia

›Prior atrial fibrillation

›Heart failure reduced ejection fraction

›Structural heart disease

Infection and bleeding risks

›Infection and bleeding risks

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›Immunosuppression

›Anticoagulation

›Antiplatelet therapy

›Hematoma after implant history

Exposure risks

›Electromagnetic and toxin risks

›Stimulant use

›Cocaine or sympathomimetic exposure

›Carbon monoxide exposure possibility

›Significant electromagnetic interference exposure

08Differential Diagnosis/ddx64

Life threatening

›Life threatening causes

›Ventricular tachycardia (I47.2)

›Shock syncope correlation

›Wide complex tachycardia on ECG

›Ventricular fibrillation (I49.01)

›Cardiac arrest history

›Multiple ICD therapies

›Acute coronary syndrome (I21.9)

›New ischemic ECG changes

›Rising troponin pattern

›Pacemaker failure in pacer dependent patient (T82.110A)

›Failure to capture on ECG

›Profound bradycardia

›Cardiac tamponade from lead perforation (I31.4)

›Hypotension with jugular venous distension

›Pericardial effusion on ultrasound

›Pulmonary embolism (I26.99)

›Hypoxia with tachycardia

›Pleuritic pain or hemoptysis

›CIED infection with bacteremia or endocarditis (T82.7XXA)

›Fever with pocket changes

›Positive blood cultures

Common

›Common causes

›Inappropriate ICD shock from supraventricular tachycardia

›Narrow complex tachycardia history

›Shock during exertion with palpitations

›Atrial fibrillation with rapid ventricular response (I48.91)

›Irregularly irregular rhythm

›Rate related symptoms

›Lead fracture or insulation failure (T82.110A)

›Intermittent sensing abnormalities

›Noise on interrogation history

›Pacemaker mediated tachycardia

›Regular tachycardia near upper tracking rate

›Retrograde P waves pattern on ECG

›Battery depletion elective replacement indicator

›Change in pacing mode

›New bradycardia or fatigue

›Vasovagal syncope (R55)

›Typical prodrome

›Normal device function on interrogation

Less common

›Less common causes

›Twiddler syndrome with lead displacement (T82.120A)

›Pocket manipulation history

›Change in lead position on chest radiograph

›Oversensing from electromagnetic interference

›Symptom timing near exposure

›Inhibition of pacing on ECG pattern

›Myocarditis (I40.9)

›Viral prodrome

›Troponin elevation with non ischemic ECG

›Electrolyte mediated arrhythmia

›Hypokalemia

›Hypomagnesemia

Mimics and non cardiac

›Mimics

›Seizure

›Tongue bite history

›Post event confusion

›Orthostatic hypotension

›Volume depletion history

›Postural symptom pattern

›Anxiety or panic

›Normal rhythm during symptoms

›Reassuring cardiopulmonary evaluation

09Past Medical History/pmh18

Cardiac history

›Cardiac history

›Indication for device

›Prior myocardial infarction

›Prior revascularization

›Heart failure stage and baseline symptoms

›Prior arrhythmia ablation

›Baseline ejection fraction

Device and procedural history

›Device history

›Prior lead extraction

›Prior pocket revision

›Prior device infection

›Device advisory or recall history

Other relevant history

›Comorbidities

›Chronic kidney disease

›Diabetes mellitus

›COPD

›Obstructive sleep apnea

›Thyroid disease

10Physical Exam/exam33

General and hemodynamics

›General assessment

›Toxic appearance

›Perfusion assessment

›Mental status

›Volume status

Cardiovascular

›Cardiovascular exam

›Rate and rhythm assessment

›Murmur new or changed

›Jugular venous distension

›Peripheral edema

›Signs of tamponade physiology

Respiratory

›Respiratory exam

›Work of breathing

›Crackles

›Wheeze

›Asymmetric breath sounds

Device pocket and leads

›Pocket exam

›Erythema

›Warmth

›Fluctuance

›Drainage

›Skin erosion

›Tenderness

›Hematoma size and tension

Neurologic and trauma

›Neuro and trauma screen

›Focal neurologic deficit

›Postictal features

›Head or facial trauma from syncope

›Cervical spine pain after fall

Special populations considerations

›Special populations exam

›Pregnancy uterine size considerations for imaging decisions

›Pediatric device location and growth related lead strain

›Anticoagulated patient bruising and pocket bleeding

11Lab Studies/labs20

Core ED labs

›Baseline labs

›CBC for anemia and leukocytosis

›Electrolytes including potassium

›Magnesium level

›Creatinine and renal function

›Glucose

Cardiac and ischemia evaluation

›Cardiac labs

›Troponin trend when ischemia concern

›BNP or NT proBNP when heart failure concern

Infection evaluation

›Infection labs

›Blood cultures times two if fever or pocket infection concern

›Lactate when sepsis physiology

›CRP or ESR as supportive data when unclear

Toxicology and endocrine

›Additional labs

›TSH when new arrhythmia or amiodarone exposure concern

›Toxicology testing when stimulant exposure concern

Lab interpretation pitfalls

›Pitfalls

›Mild troponin elevation after ICD shocks possible

›Electrolyte abnormalities can trigger shocks and arrhythmias

›Fever absent in early device infection

12Imaging/img19

Scoring Systems

›Decision tools

›Syncope risk stratification tool local protocol dependent

›Pulmonary embolism pretest probability tool when PE concern

›Sepsis screening criteria for infection physiology

MRI

›MRI considerations

›MRI conditional device status required before MRI

›Device and lead compatibility required

›Coordination with device team for mode programming

›Non conditional system treated as high risk without specialist protocol

›CT considerations

›CT pulmonary angiography when PE concern and appropriate renal function

›CT head when syncope with head trauma or focal neurologic findings

›Contrast nephropathy risk in CKD

›Radiation consideration in pregnancy and pediatrics

Ultrasound

›Ultrasound and POCUS

›Bedside echocardiography for pericardial effusion

›Lung ultrasound for pulmonary edema

›IVC assessment as adjunct to volume status

›Venous ultrasound for DVT when PE pathway considered

13Special Tests/spec18

Device interrogation and related diagnostics

›Device evaluation

›Urgent device interrogation for shocks or suspected malfunction

›Review of stored electrograms if available

›Battery status including elective replacement indicator

›Lead parameters sensing impedance thresholds

Chest radiograph evaluation

›Chest radiograph

›Lead position assessment compared with prior

›Lead fracture clues

›Generator position and rotation clues

Magnet response testing

›Magnet use

›Magnet effect differs by manufacturer and programming

›Pacemaker magnet typically asynchronous pacing while applied

›ICD magnet typically disables tachy therapies while applied

›Use only with monitoring and specialist input when feasible

Bedside maneuvers and monitoring

›Bedside diagnostics

›Orthostatic vitals when appropriate

›Continuous telemetry for suspected arrhythmia

›Serial neurologic checks after syncope related trauma

14ECG/ecg24

Immediate ECG priorities

›ECG triage

›12 lead ECG early for syncope or shock presentation

›Rhythm strip and telemetry correlation with symptoms

Paced rhythm interpretation

›Paced ECG interpretation

›Atrial paced spikes with P wave capture

›Ventricular paced spikes with wide QRS morphology

›Biventricular pacing pattern for CRT

›Pacing rate compared with programmed lower rate if known

Malfunction patterns

›Malfunction ECG patterns

›Failure to pace with absent pacing spikes when expected

›Failure to capture with spikes not followed by depolarization

›Undersensing with inappropriate pacing spikes

›Oversensing with inappropriate inhibition of pacing

Tachyarrhythmia patterns relevant to devices

›Tachyarrhythmias

›Monomorphic wide complex tachycardia treated as ventricular tachycardia until proven otherwise

›Polymorphic wide complex tachycardia with QT prolongation concern

›Atrial fibrillation with rapid ventricular response

›Supraventricular tachycardia triggers for inappropriate ICD therapy

High risk ECG findings

›ECG red flags

›Ischemic ST elevation or depression

›New high grade AV block

›Hyperkalemia ECG features

›Brugada pattern concern

›Preexcited atrial fibrillation concern

15Assessment/ax21

Problem representation

›Working problem list

›ICD shock presentation with stability assessment

›Syncope in patient with pacemaker or ICD

›Suspected pacemaker malfunction

›Suspected device pocket infection

›Suspected lead complication after recent implant

Severity stratification

›Severity stratification

›Unstable physiology requiring resuscitation bay

›Electrical storm suspicion with recurrent therapies

›Pacer dependent risk with suspected capture failure

›Sepsis physiology with device infection concern

Key complications to rule out

›Complication screen

›Acute coronary syndrome

›Heart failure decompensation

›Pulmonary embolism

›Pericardial effusion and tamponade

›Stroke or TIA after syncope or arrhythmia

Diagnostic uncertainty handling

›Uncertainty

›If symptoms but normal ECG and stable, prioritize device interrogation and ambulatory rhythm correlation

›If pocket findings equivocal, prioritize blood cultures and specialist input

›If intermittent symptoms, prioritize telemetry observation pathway when risk factors present

16Plan/plan29

First minutes stabilization

›Initial stabilization

›Cardiac monitor and defibrillator pads for shock presentations

›IV access and basic labs

›Oxygen for hypoxia

›Treat unstable arrhythmia per ACLS algorithms

ICD shock management

›ICD shock plan

›If unstable ventricular tachycardia, synchronized cardioversion

›If ventricular fibrillation or pulseless ventricular tachycardia, defibrillation

›If electrical storm with stability, antiarrhythmic infusion protocol dependent

›If recurrent shocks with distress and suspected inappropriate therapy, consider magnet to suspend tachy therapies with continuous monitoring and urgent cardiology involvement

Pacemaker malfunction management

›Pacemaker malfunction plan

›If symptomatic bradycardia with capture failure, transcutaneous pacing and escalation

›If pacer dependent and suspected malfunction, urgent device interrogation and cardiology

›Correct reversible causes including electrolytes and ischemia

›Avoid external electrical interference sources when identified

Pocket hematoma and bleeding

›Pocket bleeding plan

›Analgesia and local measures

›Anticoagulation management local protocol dependent

›Rapidly expanding hematoma requires urgent specialty input

Infection and endocarditis pathway

›Infection plan

›Blood cultures times two before antibiotics when feasible

›Broad spectrum antibiotics for sepsis physiology local protocol dependent

›Echocardiography pathway when bacteremia or endocarditis concern

›Early electrophysiology and infectious disease involvement for suspected CIED infection

Reassessment loop

›Reassessment

›Repeat vitals and symptom check after interventions

›Repeat ECG with symptom changes

›Telemetry review for recurrent arrhythmia

›Escalate level of care if instability develops

17Disposition/dispo25

ICU criteria

›ICU criteria

›Electrical storm

›Recurrent ventricular arrhythmia requiring continuous antiarrhythmic infusion

›Hemodynamic instability

›Suspected tamponade physiology

›Sepsis requiring vasopressors

Inpatient admission criteria

›Admission criteria

›Appropriate ICD shocks for ventricular arrhythmia

›New device malfunction affecting safety

›Pacer dependency with any suspicion of malfunction

›Suspected device infection

›Syncope with high risk ECG findings

Observation pathway criteria

›Observation criteria

›Stable single shock with unclear appropriateness pending interrogation

›Stable palpitations with device and need for telemetry correlation

›Syncope with intermediate risk features and planned urgent interrogation

Discharge criteria

›Discharge criteria

›Stable vitals with reassuring evaluation

›Device interrogation reassuring with clear explanation of symptoms

›No concerning pocket findings

›Reliable rapid follow up with device clinic

Follow up timing

›Follow up plan

›Device clinic follow up within 24 to 72 hours for recent shock or alerts

›Cardiology follow up within 1 week for medication changes

›Primary care follow up for contributing factors

18Discharge Instructions/di7

Copy discharge instructions

›Discharge text

›You were evaluated for symptoms in the setting of an implanted cardiac device

›Return immediately for fainting, chest pain, trouble breathing, repeated shocks, fever, or worsening pocket redness or drainage

›Avoid strong electromagnetic sources near your device and keep phones and magnets away from the implant site

›Take your medications as prescribed and do not stop heart rhythm medicines without medical advice

›Arrange urgent follow up with your device clinic as directed

›If you received an ICD shock today, do not drive until cleared by your clinician local protocol dependent

19References/r7

Guidelines and key sources

›Reference list

›AHA Guidelines for CPR and ECC 2020

›ESC Guidelines on cardiac pacing and cardiac resynchronization therapy 2021

›HRS Expert Consensus Statement on cardiovascular implantable electronic device lead management and extraction 2017

›MADIT II trial 2002

›SCD HeFT trial 2005

›Project instructions

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.