Epi_Pace

Pacing Week Pacing Week PresentationsPresentations

Epicardial Pacing OverviewEpicardial Pacing OverviewLiterature Review: Epicardial Pacing TrLiterature Review: Epicardial Pacing Trendsends

Epicardial Pacing ProceduresEpicardial Pacing ProceduresTroubleshooting Pacing ProblemsTroubleshooting Pacing Problems

Epicardial Pacing Epicardial Pacing OverviewOverview

What is epicardial pacing?What is epicardial pacing?

An artificial An artificial electricalelectrical impulse delivered to the impulse delivered to the heart via the heart via the epicardialepicardial

surface to initiate surface to initiate depolarisationdepolarisation

Why do patients need Why do patients need epicardial pacing?epicardial pacing?

CABG patientsCABG patients: cardiac output requires : cardiac output requires augmentation, depends on extent of pre-augmentation, depends on extent of pre-operative disease and incidence of operative disease and incidence of arrhythmiasarrhythmias

Valve surgery patientsValve surgery patients: conduction system : conduction system is susceptible to injury during surgery, is susceptible to injury during surgery, directly or through subsequent oedemadirectly or through subsequent oedema

Interventricular septal defectInterventricular septal defect repair repair patients: suture placement in close proximity patients: suture placement in close proximity to AV node and bundle of His.to AV node and bundle of His.

ComponentsComponents

Pacing BoxPacing Box – – generates the generates the electrical impulseelectrical impulse

Epicardial wiresEpicardial wires – – inserted surgically inserted surgically at the end of the at the end of the operationoperation

Cable leadsCable leads – – connect epicardial connect epicardial wires to the pacing wires to the pacing generatorgenerator

These wires provide a direct, low resistance These wires provide a direct, low resistance current pathway to the myocardium.current pathway to the myocardium.

Pacemaker SettingsPacemaker Settings RateRate: number of impulses generated : number of impulses generated

per minuteper minute OutputOutput (Atrial & Ventricular): amount (Atrial & Ventricular): amount

of energy delivered with each impulseof energy delivered with each impulse SensitivitySensitivity (Atrial & Ventricular): (Atrial & Ventricular):

ability of the pacemaker to sense ability of the pacemaker to sense intrinsic cardiac activityintrinsic cardiac activity

Settings required vary according to Settings required vary according to modemode

SensitivitySensitivity -- TheThe higherhigher thethe setting,setting, thethe lessless sensitivesensitive thethe pacemakerpacemaker is.is.

ForFor example,example, ifif thethe ventricularventricular sensitivitysensitivity isis setset onon 2mV,2mV, itit willwill sensesense intrinsicintrinsic activityactivity thatthat isis greatergreater inin amplitudeamplitude thanthan 2mV.2mV. However,However, ifif thethe sensitivitysensitivity isis setset atat 10mV,10mV, thethe pacemakerpacemaker willwill onlyonly sensesense intrinsicintrinsic activityactivity thatthat isis greatergreater thanthan 10mV.10mV.

10mV

2 mV

0.5 mV

At a lower setting (mV) the pacemaker is more sensitive

Pacing ModesPacing Modes International code for identifying International code for identifying

pacing modes:pacing modes: First letter = Chamber PacedFirst letter = Chamber Paced Second letter = Chamber SensedSecond letter = Chamber Sensed Third letter = Response to pacingThird letter = Response to pacing

Chambers: A=Atria, V=Ventricle, Chambers: A=Atria, V=Ventricle, D=DualD=Dual

Responses: I=Inhibited, T=Triggered, Responses: I=Inhibited, T=Triggered, D=DualD=Dual

((‘O’ indicates a null value‘O’ indicates a null value))

Pacemaker ResponsesPacemaker Responses

InhibitedInhibited - - sensed intrinsic sensed intrinsic cardiac activity will inhibit the cardiac activity will inhibit the pacemaker from generating an pacemaker from generating an impulse impulse

Triggered Triggered - - a sensed event will a sensed event will trigger another event. trigger another event.

DualDual responseresponse: : allows for an inhibited or a triggered allows for an inhibited or a triggered

response (only possible in the dual response (only possible in the dual chamber mode) chamber mode)

Example of dual response: sensed Example of dual response: sensed atrial activity atrial activity inhibitsinhibits an atrial output an atrial output but also but also triggerstriggers an AV delay. an AV delay.

If at the end of the AV delay there has If at the end of the AV delay there has been no intrinsic ventricular output, been no intrinsic ventricular output, the pacemaker will generate an the pacemaker will generate an impulse.impulse.

DDD Specific SettingsDDD Specific Settings Atrial TrackingAtrial Tracking: A sensed atrial event not : A sensed atrial event not

only inhibits atrial pacing but also triggers only inhibits atrial pacing but also triggers the AV interval.the AV interval.

A-V Interval: A-V Interval: Aims to optimise cardiac Aims to optimise cardiac output by synchronising atrial and output by synchronising atrial and ventricular depolarisation (often described ventricular depolarisation (often described as the “electronic” PR interval). as the “electronic” PR interval).

Length of time in milliseconds (ms) that is allowed Length of time in milliseconds (ms) that is allowed to elapse between a paced or sensed atrial event to elapse between a paced or sensed atrial event and the delivery of a paced ventricular impulse. and the delivery of a paced ventricular impulse.

Upper Rate Limit: Upper Rate Limit: Maximum ventricular Maximum ventricular pacing rate allowed while atrial tracking is pacing rate allowed while atrial tracking is on. on. If atrial rate becomes too fast, upper rate limit If atrial rate becomes too fast, upper rate limit

prevents atrial-tracking function from allowing a prevents atrial-tracking function from allowing a ventricular response to continue past a safe ventricular response to continue past a safe rate. Limit is determined by rate setting + rate. Limit is determined by rate setting + 30PPM or 110PPM (whichever is greater).30PPM or 110PPM (whichever is greater).

PVARPPVARP (Post-ventricular atrial refractory (Post-ventricular atrial refractory period): the length of time following a period): the length of time following a ventricular event when atrial sensing is ventricular event when atrial sensing is inactivated. This avoids the pacemaker inactivated. This avoids the pacemaker sensing T-wave as atrial activity.sensing T-wave as atrial activity.Setting automatically determined by the base rate Setting automatically determined by the base rate

(<100 ->300ms, 100-150 ->250ms …)(<100 ->300ms, 100-150 ->250ms …)

What mode is this?What mode is this?

VVI or…VVI or…DDD with Atrial Tracking ‘On’, AV interval DDD with Atrial Tracking ‘On’, AV interval

160ms160ms

Explains why sometimes monitored rate is faster than Explains why sometimes monitored rate is faster than pacemaker rate setting – patient’s atrial rate is faster pacemaker rate setting – patient’s atrial rate is faster and atrial tracking function is onand atrial tracking function is on

What mode is this?What mode is this?

Pacing Pacing BoxBox

Press ON. The pacemaker will perform Press ON. The pacemaker will perform a power on self-test that lasts about 4 a power on self-test that lasts about 4 secondsseconds The back light will come on and Dual The back light will come on and Dual

Chamber pacing and sensing begins at Chamber pacing and sensing begins at preset values.preset values.

Requires a 9V batteryRequires a 9V battery

NOTE: pressing the Emergency key also NOTE: pressing the Emergency key also turns the device on.turns the device on.

Turning it onTurning it on

Default Values: Default Values:

Mode: DDDMode: DDD Rate 80Rate 80 A Output 10 mAA Output 10 mA V Output 10 mAV Output 10 mA A Sensitivity 0.5 mVA Sensitivity 0.5 mV V Sensitivity 2.0 mVV Sensitivity 2.0 mV

Emergency KeyEmergency Key

Pressing this key will initiate high Pressing this key will initiate high output dual chamber asynchronous output dual chamber asynchronous pacing at rate of 80 (or previous pacing at rate of 80 (or previous setting)setting) What mode will this be?What mode will this be?

Pressing the ON key will resume Dual Pressing the ON key will resume Dual Chamber Demand (synchronous) Chamber Demand (synchronous) pacing.pacing.

Lock/Unlock KeyLock/Unlock Key

Locks and unlocks the three upper dials.Locks and unlocks the three upper dials. When it is locked the padlock icon When it is locked the padlock icon

appears and these values cannot be appears and these values cannot be changed.changed.

Automatically locks after 60 seconds.Automatically locks after 60 seconds. ON, OFF, MENU, EMERGENCY, and ON, OFF, MENU, EMERGENCY, and

PAUSE keys also unlock the upper dials.PAUSE keys also unlock the upper dials.

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Literature Literature Review: Review:

Epicardial pacing Epicardial pacing trendstrends

PAH StatisticsPAH Statistics

What is epicardial pacing used What is epicardial pacing used for postoperatively?for postoperatively?

Takeda, M. et al (1996) Cardiovasc. Takeda, M. et al (1996) Cardiovasc. SurgerySurgery

Reviewed reasons for pacing (used in 54% of Reviewed reasons for pacing (used in 54% of cardiac surgical patients):cardiac surgical patients): Rapid atrial pacing to interrupt SVTRapid atrial pacing to interrupt SVT Improve cardiac output in bradycardic Improve cardiac output in bradycardic

patientspatients Suppress PACs and atrial tachycardiasSuppress PACs and atrial tachycardias

RecommendationRecommendation - Should be used in preference - Should be used in preference to antiarrhythmic medications post-opto antiarrhythmic medications post-op

Should all cardiac surgical Should all cardiac surgical patients have epicardial pacing patients have epicardial pacing

wires?wires?Puskas, J. et al (2003) Heart Surgery ForumPuskas, J. et al (2003) Heart Surgery Forum Studied patients undergoing either Studied patients undergoing either

conventional CABG or off-pump CABGconventional CABG or off-pump CABG PW were placed prior to chest closure PW were placed prior to chest closure

according to according to criteria-driven protocolscriteria-driven protocols Bradycardia with low cardiac outputBradycardia with low cardiac output nodal or junctional arrhythmiasnodal or junctional arrhythmias AV blocksAV blocks

FindingsFindings:: 33 out of 197 (17%) of patients 33 out of 197 (17%) of patients

required PWrequired PW No patient without PW required No patient without PW required

pacing postoperatively by any other pacing postoperatively by any other means or had other complications means or had other complications related to avoidance of PWrelated to avoidance of PW

RecommendationRecommendation – current criteria – current criteria driven protocols are accurate in driven protocols are accurate in predicting which patients require predicting which patients require pacing postoperativelypacing postoperatively

Does the pacing mode used Does the pacing mode used influence coronary graft flow? influence coronary graft flow?

D’Ancona, G. et al (2004) Eu J. Cardiothoracic D’Ancona, G. et al (2004) Eu J. Cardiothoracic SurgSurg

Studied CABG flow post weaning of CPBStudied CABG flow post weaning of CPB

First studyFirst study: compared flow rates : compared flow rates between DDD and VVI pacing modesbetween DDD and VVI pacing modes Findings: DDD improves haemodynamic Findings: DDD improves haemodynamic

state and therefore graft flowstate and therefore graft flow

Second studySecond study: compared flow rates in : compared flow rates in DDD mode with different AV intervalsDDD mode with different AV intervals Findings – systemic haemodynamics are Findings – systemic haemodynamics are

not influenced by length of AV delay, not influenced by length of AV delay, however, coronary graft flow is however, coronary graft flow is maximised at 175msmaximised at 175ms

RecommendationsRecommendations – in patients – in patients requiring DDD pacing, an AV interval requiring DDD pacing, an AV interval of 175ms is optimal.of 175ms is optimal.

Does atrial epicardial pacing Does atrial epicardial pacing prevent AF after heart surgery?prevent AF after heart surgery?Daoud, E. et al (2002) Journal of Cardiovascular Daoud, E. et al (2002) Journal of Cardiovascular

ElectrophysiologyElectrophysiology Performed a meta-analysis to assess the effect Performed a meta-analysis to assess the effect

of pacing therapies for prevention of post-op AFof pacing therapies for prevention of post-op AF Reviewed 8 trials, total 776 patients, looking Reviewed 8 trials, total 776 patients, looking

at:at: Location of pacing wires – right atrial, left atrial or Location of pacing wires – right atrial, left atrial or

biatrialbiatrial Pacing algorithm - overdrive pacing (set rate 10 Pacing algorithm - overdrive pacing (set rate 10

above sinus rate) v. fixed high-rate pacing (rates 80-above sinus rate) v. fixed high-rate pacing (rates 80-100)100)

None of the trials used antiarrhythmics in None of the trials used antiarrhythmics in combination with pacingcombination with pacing

FindingsFindings:: Overdrive biatrial and right atrial Overdrive biatrial and right atrial

pacing, and fixed high-rate biatrial pacing, and fixed high-rate biatrial pacing demonstrated a significant pacing demonstrated a significant reduction in incidence of AF (2½ times reduction in incidence of AF (2½ times less likely)less likely)

RecommendationsRecommendations - Pacing therapy is - Pacing therapy is preferred to medications for AF preferred to medications for AF prophylaxis as it is less expensive & prophylaxis as it is less expensive & has less risk of arrhythmia has less risk of arrhythmia complications and hypotension.complications and hypotension.

Is biatrial (left & right) pacing Is biatrial (left & right) pacing better at preventing AF than better at preventing AF than

right only?right only?Debrunner, M. et al (2004) Eu Journal of Debrunner, M. et al (2004) Eu Journal of

Cardiothoracic SurgeryCardiothoracic Surgery Studied patients with no history of AF, Studied patients with no history of AF,

undergoing valve surgery +/- CABGundergoing valve surgery +/- CABG Control group – standard atrial wiresControl group – standard atrial wires Treatment group - additional wire in L) atrium Treatment group - additional wire in L) atrium

to achieve bi-atrial pacing (BAP)to achieve bi-atrial pacing (BAP)

Paced in AAI at a rate 10 above intrinsic Paced in AAI at a rate 10 above intrinsic rate, for 72hours post-oprate, for 72hours post-op

FindingsFindings:: ProphylacticProphylactic BAPBAP reducedreduced thethe incidenceincidence

ofof AFAF byby halfhalf whenwhen comparedcompared toto controlcontrol groupgroup (BAP(BAP isis thoughtthought toto promotepromote inter-inter-atrialatrial synchrony).synchrony).

OverOver 60%60% ofof episodesepisodes ofof AFAF occurredoccurred betweenbetween 24-72hrs24-72hrs post-op.post-op.

RecommendationsRecommendations –– BAPBAP isis moremore efficientefficient atat preventingpreventing AFAF thanthan conventionalconventional pacingpacing whenwhen usedused upup toto 72hrs72hrs post-op.post-op.

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Epicardial Pacing Epicardial Pacing ProceduresProcedures

Changing Pacing Mode:Changing Pacing Mode:Demand/Synchronus PacingDemand/Synchronus Pacing

On arrival from OT change patient to a On arrival from OT change patient to a demand mode of pacing (eg. AAI, DDD)demand mode of pacing (eg. AAI, DDD) During demand (synchronous) pacing, During demand (synchronous) pacing,

output is inhibited when the pacemaker output is inhibited when the pacemaker senses intrinsic activity.senses intrinsic activity.

This minimizes competition between the This minimizes competition between the paced rhythm and the intrinsic activity of paced rhythm and the intrinsic activity of the heart.the heart.

Why are patient’s in an asynchronus Why are patient’s in an asynchronus pacing mode in OT?pacing mode in OT?

To change to demand mode: turn To change to demand mode: turn sensitivity settings on (Atrial and/or sensitivity settings on (Atrial and/or Ventricular) or use Dial-a-mode Ventricular) or use Dial-a-mode functionfunction

To change from DDD to single chamber To change from DDD to single chamber demand pacing, set:demand pacing, set: A Output to OFF (DDD -> VVI)A Output to OFF (DDD -> VVI) V Output to OFF (DDD -> AAI)V Output to OFF (DDD -> AAI)

Works in reverse to return to dual pacingWorks in reverse to return to dual pacing

Viewing the Intrinsic Viewing the Intrinsic RhythmRhythm

Avoid this in the early postoperative periodAvoid this in the early postoperative period PAH policy is not to use the PAUSE button.PAH policy is not to use the PAUSE button.

This button suspends all pacing and sensing This button suspends all pacing and sensing functions for up to ten seconds.functions for up to ten seconds.

Reduce the rate to look for loss of pacing Reduce the rate to look for loss of pacing and sensing of patients own intrinsic rate.and sensing of patients own intrinsic rate. Why? -> Remember: HR x SV = COWhy? -> Remember: HR x SV = CO

Changing the BatteryChanging the Battery

Battery indicator in the top left hand Battery indicator in the top left hand corner of the upper screen appears when corner of the upper screen appears when battery needs changing.battery needs changing.

Once this appears, the device will Once this appears, the device will operate satisfactorily for a minimum of operate satisfactorily for a minimum of 24 hours at or below a rate of 70, 24 hours at or below a rate of 70, nominal outputs and with the lower nominal outputs and with the lower screen inactive.screen inactive. Best to change as soon as indicator appearsBest to change as soon as indicator appears

It is not recommended to replace the It is not recommended to replace the battery while the device is turned on.battery while the device is turned on.

PAH Guideline is to set up another PAH Guideline is to set up another pacing box with new battery (9V) and pacing box with new battery (9V) and change over pacing cables to the change over pacing cables to the new box.new box.

Checking Output Checking Output Threshold/sThreshold/s

Output/stimulation threshold is the Output/stimulation threshold is the leastleast amount of current required to amount of current required to elicit cell depolarisation.elicit cell depolarisation.

Not routinely performed in the first Not routinely performed in the first 12 hours postoperatively unless 12 hours postoperatively unless there are problems with pacing there are problems with pacing

((Why??)Why??)

Output threshold can be affected by:Output threshold can be affected by: faulty connections/leads faulty connections/leads flattening batteriesflattening batteries location of electrodelocation of electrode cell statuscell status

Excessively high output can cause Excessively high output can cause oedema at the contact site in the oedema at the contact site in the myocardium leading to tissue myocardium leading to tissue damage.damage.

Why is this more of a problem with Why is this more of a problem with transvenous pacing than epicardial?transvenous pacing than epicardial?

Output Threshold Test Output Threshold Test Procedure:Procedure:Atrial & Ventricular settings need to be assessed Atrial & Ventricular settings need to be assessed separatelyseparately1.1. Patient connected to temporary Patient connected to temporary

pacemaker and ECG monitoredpacemaker and ECG monitored2.2. Set pacing rate Set pacing rate 10 above10 above the intrinsic the intrinsic

rate of patient rate of patient 3.3. This adjustment ensures pacing. The This adjustment ensures pacing. The

pace indicator flashes. pace indicator flashes. 4.4. Decrease output: turn the output dial Decrease output: turn the output dial

slowly counterclockwise until ECG shows slowly counterclockwise until ECG shows loss of capture. loss of capture.

5.5. Pace and sense indicators flash Pace and sense indicators flash intermittently. intermittently.

6.6. IncreaseIncrease output:output: turnturn thethe outputoutput dialdial slowlyslowly clockwiseclockwise untiluntil ECGECG showsshows consistentconsistent capture.capture.

7.7. TheThe pacepace indicatorindicator flashesflashes continuously,continuously, thethe sensesense indicatorindicator stopsstops flashing.flashing. ThisThis valuevalue isis thethe stimulationstimulation thresholdthreshold..

8.8. SetSet outputoutput toto aa valuevalue 33 timestimes greatergreater thanthan thethe stimulationstimulation thresholdthreshold value.value. OutputOutput settingsetting shouldshould notnot bebe lessless thanthan 10mA10mA..

9.9. ReturnReturn pacingpacing raterate toto previousprevious value.value.

Checking Sensitivity Checking Sensitivity Threshold/sThreshold/s

SensitivitySensitivity settingsetting determinesdetermines thethe abilityability ofof thethe pacemakerpacemaker toto recognizerecognize anan intrinsicintrinsic impulseimpulse

SensitivitySensitivity thresholdthreshold isis thethe lowestlowest sensitivitysensitivity (highest(highest mV)mV) settingsetting requiredrequired toto consistentlyconsistently sensesense patient’spatient’s intrinsicintrinsic activity.activity.

1.1. Patient connected to temporary Patient connected to temporary pacemaker and ECG monitoring pacemaker and ECG monitoring

2.2. Set PACING RATE Set PACING RATE 10 below10 below the the intrinsic rate of patient to a minimum intrinsic rate of patient to a minimum of 40. This adjustment ensures non-of 40. This adjustment ensures non-pacing. The sense indicator flashes.pacing. The sense indicator flashes.

3.3. Assess patient has an adequate Assess patient has an adequate intrinsic rate and that blood intrinsic rate and that blood pressure is not compromised. If pressure is not compromised. If BP compromised procedure is not BP compromised procedure is not done.done.

Sensitivity Threshold Test Sensitivity Threshold Test Procedure:Procedure:Atrial & Ventricular settings need to be assessed Atrial & Ventricular settings need to be assessed separatelyseparately

4.4. Adjust Adjust output setting to minimumoutput setting to minimum – (0.1mA) – (0.1mA) This adjustment avoids pacemaker competition with This adjustment avoids pacemaker competition with

intrinsic rhythm during the threshold test as intrinsic rhythm during the threshold test as capture is unlikely at such a low output setting.capture is unlikely at such a low output setting.

5.5. Press the Press the menumenu key until menu 1 is displayed - key until menu 1 is displayed - press the select key to highlight either Atrial or press the select key to highlight either Atrial or Ventricular sensitivityVentricular sensitivity

6.6. DecreaseDecrease sensitivity: slowly turn the menu sensitivity: slowly turn the menu parameter dial to increase the mV value until parameter dial to increase the mV value until PACE indicator flashes continuously. PACE indicator flashes continuously. The The sense indicator stops flashingsense indicator stops flashing. The pace . The pace

indicator flashes continuously, but capture is not indicator flashes continuously, but capture is not likely because the output value is at minimum. likely because the output value is at minimum.

7.7. IncreaseIncrease sensitivity:sensitivity: slowlyslowly turnturn thethe menumenu parameterparameter dialdial toto decreasedecrease thethe mVmV valuevalue untiluntil thethe sensesense indicatorindicator flashesflashes consistentlyconsistently andand thethe pacepace indicatorindicator stopsstops flashing.flashing.

ThisThis valuevalue isis thethe sensingsensing thresholdthreshold

7.7. SetSet sensitivitysensitivity toto halfhalf thethe thresholdthreshold valuevalue (eg.(eg. IfIf thresholdthreshold valuevalue == 5.0mV,5.0mV, setset sensitivitysensitivity toto 2.5mV2.5mV thisthis providesprovides aa 2:12:1 safetysafety margin).margin).

8.8. RestoreRestore pacingpacing raterate andand outputoutput settingssettings (A(A oror V)V) toto previousprevious values.values.

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Troubleshooting Troubleshooting Pacing ProblemsPacing Problems

What is the problem here and would you do if this happened?

Problem: Failure to CaptureProblem: Failure to Capture

Actions:Actions: Increase ventricular outputIncrease ventricular output Check connections and battery Check connections and battery Commence CPR if necessaryCommence CPR if necessary Myocardium may not be viableMyocardium may not be viable

If this happens with transvenous If this happens with transvenous pacing - turn patient onto left sidepacing - turn patient onto left side

What would you do if this happened?

Also, what mode is the pacemaker likely to be in?

Problem: Failure to SenseProblem: Failure to Sense

Actions:Actions: Increase sensitivity setting: decrease mV Increase sensitivity setting: decrease mV

to make the pacemaker more sensitive to to make the pacemaker more sensitive to the patient’s own rhythmthe patient’s own rhythm

Change to DDD mode if currently in DOOChange to DDD mode if currently in DOO Check/change battery – sensing function Check/change battery – sensing function

can often be first to go if battery power is can often be first to go if battery power is lowlow

If problem continues assess adequacy of If problem continues assess adequacy of intrinsic rhythm and decrease rate or intrinsic rhythm and decrease rate or discontinue pacingdiscontinue pacing

What is the problem here and what would you do if this happened?

Problem: Over-sensingProblem: Over-sensing

Actions:Actions: Ensure connections are tight and secureEnsure connections are tight and secure Observe sensing light. If sense light is flashing Observe sensing light. If sense light is flashing

where there is no intrinsic QRS complex, where there is no intrinsic QRS complex, decrease ventricular sensitivitydecrease ventricular sensitivity

If inappropriate sensing continues without If inappropriate sensing continues without adequate underlying rhythm - change to adequate underlying rhythm - change to asynchronous modeasynchronous mode

Remove/treat potential causes of artifact (eg. Remove/treat potential causes of artifact (eg. shivering, electrical interference)shivering, electrical interference)

How is this patient feeling at How is this patient feeling at the moment?!the moment?!

Problem: Failure to PaceProblem: Failure to Pace

Actions:Actions: Check all connections from patient, Check all connections from patient,

pacing cable and pacemakerpacing cable and pacemaker Check/change batteryCheck/change battery Commence CPR if necessaryCommence CPR if necessary Check for loose / broken wiresCheck for loose / broken wires

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