CPR on Patients with Pacemakers

Standard CPR Protocol Applies

• The American Heart Association recommends initiating high-quality chest compressions immediately at 100-120 compressions per minute with depth of at least 2 inches, allowing complete chest recoil between compressions, for patients with pacemakers who are in cardiac arrest 1, 2
• The American Heart Association guidelines make no distinction or modification to CPR technique based on the presence of a pacemaker or implantable cardioverter-defibrillator (ICD), with a strength of evidence level not specified 3, 4

Defibrillation Considerations with Pacemakers

• When defibrillation is needed, the American Heart Association recommends placing pads/paddles at least 8 cm away from the pacemaker generator if possible, but do not delay shock delivery to achieve ideal positioning, with acceptable pad placements including anterior-posterior and anterior-lateral positions on the chest wall 5, 6
• The risk of pacemaker or ICD malfunction after external defibrillation when pads are placed in close proximity to the device generator is acceptable given the alternative is death, according to the American Heart Association 6

Device-Specific Interventions

• If the patient has epicardial pacing wires already in place, attempt immediate pacing for asystole or bradycardic arrest, but initiate CPR if pacing is not successful within 1 minute, as recommended by the American College of Cardiology [1, 7 is ignored in favor of 1]

Common Pitfalls to Avoid

• The American Heart Association advises never to withhold or delay CPR due to concerns about damaging the pacemaker device, as case reports have rarely described damage to implanted devices from external chest compressions, but the certain death without CPR far outweighs this minimal risk 1