N’hem parlat també a l’EMPodCat .
En molts serveis d’urgències disposem d’una eina per poder tractar les bradicàrdies simptomàtiques greus, el marcapassos transcutani. Aquest dispositiu l’acostumem a trobar en els monitors desfibril·ladors moderns. Com tots els marcapassos, el seu funcionament consisteix a administrar descàrregues elèctriques sobre el miocardi per a provocar una contracció cardíaca i la consegüent ejecció de sang. A diferència dels marcapassos interns o transvenosos, aquesta descàrrega elèctrica no es fa través d’un elèctrode en contacte amb l’interior de les cavitats cardíaques, sinó a través d’uns pegats conductors transcutanis. Habitualment aquests pegats són els mateixos que els de desfibril·lació i la seva ubicació al tòrax també és la mateixa (potser la posició anteroposterior és millor que l’anterolateral).
Monitor Corpuls3 en mode marcapassos
Llegeix més: Falsa captura del marcapassos transcutani
Per a aconseguir aquest batec el marcapassos ha d’administrar una descàrrega elèctrica que sigui capaç de vèncer tota la resistència de la pell, musculatura i la resta de la caixa toràcica per arribar fins al miocardi i allà provocar la contracció ventricular. Aquestes descàrregues són molt més potents que les dels marcapassos interns, provoquen contraccions musculars intenses i són doloroses per al pacient.
VIDEO
Exemple de marcapassos transcutani en funcionament en un voluntari
Aquest procés de provocar el bàtec cardíac s’anomena captura, primer s’ha d’aconseguir el que s’anomena captura elèctrica. N’hi diem elèctrica perquè podem veure en el monitor cardíac com es produeix l’espícula de la descàrrega del marcapassos seguida d’un complex que recorda a un QRS estrany o ample i una ona T discernible . Però que el nostre monitor detecti aquesta captura elèctrica no implica que aquesta descàrrega hagi originat un batec efectiu capaç de bombar sang. Aquest batec efectiu és el que anomenem captura mecànica o captura veritable i és que realment perseguim quan posem un marcapassos a algú.
Tira de monitor d’una captura elèctrica de marcapassos transcutani. S’observen les espícules seguides d’un QRS ample i una onda T perfectament discernibles. Imatge de ems12lead.com
Aconseguir la captura mecànica no és trivial i molt sovint no s’aconsegueix i no és detectat pels sanitaris que han iniciat la teràpia. El passat març de 2024 es va publicar un article sobre aquest problema de la falsa captura en el medi prehospitalari i tot de vídeos i publicacions que el van seguir.
Els números que mostra aquesta sèrie de casos són francament molt dolents i ens han de fer repensar si realment apliquem correctament aquesta teràpia.
Com podem assegurar que tenim captura mecànica del marcapassos? Doncs tenim a la nostra disposició diverses eines, no totes igual d’eficaces, vegem-les una per una:
ECG
És l’eina més immediata, però alhora potser és la més enganyosa. En la captura elèctrica observarem l’espícula de la descàrrega seguida d’un complex que recorda un QRS ample. La presència d’ona T reconeixible darrere aquest complex ens fa pensar que puguem tenir captura mecànica. Si no hi és n’hauríem de dubtar i considerar que és una falsa captura elèctrica.
Tinguem present que després de la descàrrega del marcapassos, l’aparell ens mostrarà una certa aberració en els QRS de l’ECG, que algú anomena complex fantasma , que pot fer-nos confondre en la presència d’aquesta ona T.
Infografia de Foamfrat il·lustrant el concepte de complex fantasma i la falsa captura Font Foamfrat
Possiblement, a causa d’aquest fet, fins i tot un fabricant d’aparells ha publicat una nota advertint d’aquesta possibilitat , aquest complex fantasma que ens mostra es deu bàsicament a una pausa de 40-80 ms en el registre que fan els aparells per evitar una aberració més llarga si l’aparell estigués mesurant contínuament. És possible també veure complexos nadius del pacient entre els generats pel marcapassos, això també ens hauria de fer dubtar de la presència de captura.
Tira de ritme que mostra una falsa captura elèctrica. Font: Stryker. Pacing artifact may masquerade as capture
Cal tenir present que la freqüència que ens mostrarà el monitor pot no correspondre’s a la real del pacient. Ens pot comptar els complexos que no condueixen i no comptar els batecs nadius del pacient.
Pols
Possiblement la menys útil, fins i tot contraproduent. En l’estudi referenciat , els paramèdics van detectar pols palpable en tots els 23 casos, tot i que els autors consideren que només 4 pacients tenien captura elèctrica veritable.
Tira de ritme que mostra una falsa captura elèctrica però en que els paramèdics reporten pols palpable. Encerclat un exemple de complex fantasma. Font: False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series
És possible que la contracció de la musculatura toràcica provoqui un moviment capaç d’enganyar-nos quan prenem el pols, però possiblement com més distal sigui el lloc de mesura de la contracció muscular menys afectat estarà. Des del meu punt de vista NO l’hauríem de fer servir per decidir si el marcapassos funciona o no, i si mesurem el pols ho farem preferiblement a l’artèria femoral que, potser, no estarà tant artefactada per la contracció muscular toràcica.
Capnografia
Una eina molt interessant, ja que es correlaciona amb el cabal cardíac. Si el marcapassos provoca batecs efectius això ens augmentarà la freqüència cardíaca i, per tant, el cabal cardíac. Si hem mesurat l’EtCO2 abans d’iniciar la teràpia i aquest valor augmenta de forma considerable un cop iniciada és un signe d’eficàcia del tractament . Si no ho hem mesurat abans de l’inici de l’estimulació és difícil saber si el número que veiem es deu a l’eficàcia de la teràpia o no. Hem de ser conscients de les limitacions en la capnografia, especialment en la modalitat no invasiva, i si l’estímul dolorós ens augmenta la freqüència respiratòria això també afectarà el valor de l’EtCO2.
Tira de ritme d’un pacient intubat i amb marcapassos transcutani. En la tira superior s’observa un augment de l’EtCO2 coincidint amb la captura mecànica. Observeu com l’ECG és pràcticament idèntic en les dues tires. Font: Using Capnography to Confirm Capture with Transcutaneous Pacing
Pressió arterial
Si disposéssim de pressió arterial invasiva aquest seria un mètode molt eficaç, ja que per cada batec efectiu en veuríem la corba al monitor. Desconec si hi hauria diferència entre tenir el sensor a una artèria radial respecte a una femoral. Però de tota manera, com que l’ús de la PA invasiva és anecdòtic ens haurem de conformar amb els nostres braçals automàtics. En l’estudi al qual hem fet referència i algun altre els pacients amb captura veritable van mostrar un augment considerable de la pressió sistòlica. Desconec fins a quin punt aquest augment es pot atribuir directament a l’eficàcia de la teràpia i no al fet que en haver-hi una freqüència cardíaca més alta la mesura és de millor qualitat.
Ecografia
Per què conformar-nos a mesurar coses indirectament quan podem veure-les directament? Doncs això és el que podem aconseguir amb l’ecografia. Si obtenim una bona visió abans d’iniciar el marcapassos i veiem la bradicàrdia i la funció cardíaca, la podem comparar un cop el marcapassos està disparant. Si veiem que la freqüència augmenta que més ens cal? I a la inversa, si a pesar de les descàrregues del marcapassos la freqüència no augmenta podem estar ben segurs que no hi ha captura mecànica.
Aquesta eina fa ben bé una vintena d’anys que s’aplica, se n’han publicat casos clínics i algun estudi una mica més nombrós , però com podem esperar no és perfecte. No tots els pacients tenen una bona finestra ecogràfica, o potser els professionals no tenen l’aparell o no el saben fer servir, o amb tant moviment no és possible mantenir una bona visió del cor. I com tot el que té a veure amb ecografia és operador depenent i no sempre dues persones es posaran d’acord en el que veuen.
Batec provocat pel marcapassos. Observeu la pobra funció cardíaca Font: Hill et al .
Vídeo que mostra el procés de captura de marcapassos. Font: coreultrasound
Nivell de consciència
De nou un signe dubtós, certament si el marcapassos provoca batecs eficaços augmentarà el cabal cardíac, i si aquesta n’és la causa, ens pot millorar el baix nivell de consciència. Però alhora només l’estímul dolorós que provoca la descàrrega del marcapassos ja pot fer que el nostre pacient estigui més “despert”. Si hi afegim que hauríem de proveir sedoanalgèsia adequada als pacients als quals apliquem aquesta teràpia ens fa que aquest signe sigui poc útil.
SpO2
Aquesta és una eina interessant, no pas pel valor de la saturació sinó per l’ona pletismogràfica que ens proporciona. Si reconeixem ones a la mateixa freqüència que la programada al marcapassos podem estar bastant segurs que hi ha captura mecànica i un batec efectiu, però tampoc ens en podem refiar al 100% . En cas contrari, si la freqüència és (notòriament) inferior a la programada haurem de dubtar de la captura mecànica. Evidentment, si el traçat pletismogràfic és dolent no tampoc no ens podem refiar.
Tira de ritme que mostra inici de descàrregues del marcapassos a la part superior i l’ona pletismogràfica a la part inferior, en una frequüència molt inferior. Font: ems12lead
Tira de ritme que descàrregues del marcapassos a la part superior i l’ona pletismogràfica a la part inferior sincrònica amb gairebé tots els complexos QRS Font: ems12lead
Potència marcapassos
Certament, aquest ítem no té res a veure amb allò que podem observar en el pacient, però el fem constar perquè sembla que potències baixes no aconsegueixen la captura mecànica. Com a referència, potències per sota de 85 mA difícilment aconseguiran la captura mecànica .
Un cop estem segurs que ja tenim captura mecànica es considera adequat pujar una mica la potència (10 mA o un 25% segons on llegeixis) per garantir que aquesta es mantindrà tot i els canvis que hi pugui haver, mobilització del pacient, dels elèctrodes…, però tinguem present que és molt possible que es perdi la captura mecànica a mesura que el temps de teràpia avançi i ens calgui anar augmentant aquesta energia administrada.
I que podem fer amb tota aquesta informació? Jo em quedo amb la idea que assegurar l’eficàcia d’aquesta teràpia només es pot fer si diversos signes alhora semblen indicar que hi ha captura mecànica. No tots els signes tenen el mateix pes, l’ecografia, pulsioximetria, pressió arterial i capnografia són força creïbles, la palpació del pols, no. Cal evitar ser excessivament optimista i creure’ns que només per engegar la màquina aquesta ja funciona.
Saber-ne més
Lloc web ems12lead , amb molts exemples de marcapassos transcutani
Medscape: Transcutaneous Cardiac Pacing
Bibliografia
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