When an individual collapses and is unresponsive, the priority is to immediately initiate life-saving care, which includes calling for emergency medical services and starting cardiopulmonary resuscitation (CPR). The presence of a medical device, such as a pacemaker, should never cause a rescuer to hesitate or delay intervening in a cardiac emergency. While pacemakers are designed to regulate heart rhythm, they do not prevent a person from experiencing sudden cardiac arrest. Any adjustments made to the standard resuscitation protocol are secondary to the need for rapid, high-quality chest compressions and, if available, the use of an automated external defibrillator (AED). This information serves as a guide for these necessary adjustments.
Identifying the Device Location
The first step in adjusting the rescue technique is to quickly locate the pacemaker on the victim’s body. Pacemakers are typically implanted just beneath the skin and fat, creating a visible or palpable bulge. This device is usually situated in the upper chest, most commonly below the collarbone on the left side of the body.
The device is generally a small, hard lump about the size of a deck of cards, with a scar often present over the implant site. While the left side is standard, the device may occasionally be placed on the upper right side of the chest, so a rescuer should quickly scan both areas. A quick visual and light physical inspection of the chest is the fastest way to confirm the location in an emergency.
Adjustments for Chest Compressions
If a victim with a pacemaker is unresponsive and not breathing normally, chest compressions must begin immediately without delay. The standard technique for compression involves placing the heel of one hand on the center of the chest, on the lower half of the breastbone. The pacemaker is usually located higher up on the chest near the collarbone, well away from the standard compression site.
The primary instruction is to perform compressions as normally as possible, focusing on a rate of 100 to 120 compressions per minute and a depth of at least two inches. The rescuer should aim to avoid placing their hands directly over the pacemaker device if it is visible or felt. The concern is the theoretical risk of damaging the device, but the life-saving benefit of immediate CPR significantly outweighs this minimal risk. If the device is uncommonly positioned and interferes with standard hand placement, compressions must still be delivered hard and fast, as the need for blood flow is paramount.
Safe Use of an Automated External Defibrillator
An Automated External Defibrillator (AED) should be used on a victim with a pacemaker, as defibrillation is the definitive treatment for many forms of sudden cardiac arrest. The only critical adjustment required is in the placement of the electrode pads to ensure the electrical current does not pass directly through the implanted device. Placing a pad directly over the pacemaker could potentially damage the device or interfere with the delivery of the therapeutic shock.
To avoid this, the AED pads must be placed at least one inch away from the location of the pacemaker, with some guidelines suggesting a minimum distance of three centimeters or 8 centimeters if possible. If the standard anterolateral pad placement—one pad on the upper right chest and the other on the lower left side—would position a pad near or over the device, an alternative placement should be used.
Alternative Pad Placement
The rescuer has two primary options for alternative placement:
- Use an anterior-posterior configuration, placing one pad on the front of the chest and the other on the back.
- Shift the pads to avoid the bulge of the device.
The priority remains delivering the shock as quickly as possible, and pad placement should not delay this action.