Diathermy, pacemakers and electromagnetic interference

[1]

One-line exam answer

CIED safety during electrosurgery is geometry plus sensing plus contingency: keep monopolar current out of the generator–heart axis, prefer bipolar, manage ICD therapies deliberately, and keep external pacing or defibrillation ready.[1][5]

Core tables

Mechanisms and risk

EMI couples into sensing circuits, especially when current traverses the generator–lead loop. Pacemakers may inhibit; ICDs may shock. Magnets may force asynchronous pacing or suspend tachy detection — device-specific, not universal. MRI is a separate conditional EMI domain.[5] Higher risk if pacing-dependent, monopolar near generator, continuous energy, active ICD therapies, or thoracic current path.

Theatre bundle

Identify device and dependence; cardiology when needed; continuous ECG and pulse waveform; bipolar if possible; short lowest-power monopolar bursts; contralateral plate avoiding generator axis; magnet or programming plan; external pads not over generator; re-enable ICD therapies after surgery; interrogate after heavy EMI.[1][5] Implant and extraction pathways add perforation, tamponade, infection and air embolism as related complications.[2][6][7][8]

SAQ and viva

Contrast monopolar and bipolar; EMI on pacemaker versus ICD; high-risk features; ICD laparotomy plan; magnet limits; post-op re-enable. If asystole occurs during diathermy: stop energy, use planned magnet or external pacing, defibrillate if required, treat as EMI until proven otherwise. [2]

[1] [1]

Extended viva bank (high-yield stems)

Stem A — definitions under pressure. Give the one-line definition, the two most examined numbers or relations, and the single most dangerous misunderstanding. Keep this under forty-five seconds. [3]

Stem B — mechanism to bedside. Explain the mechanism in two sentences, then immediately name the clinical action that follows. Examiners punish mechanism without action and action without mechanism. [4]

Stem C — compare and choose. Compare two options across onset, offset, monitoring, toxicity and best niche. End with a choice for a stated patient. [5]

Stem D — crisis choreography. Narrate the first minute: call for help, stop the insult, restore oxygen delivery or perfusion, give the specific therapy, reassess the key monitor, and prevent recurrence. [6]

Stem E — special population twist. Repeat your standard answer for pregnancy, paediatrics, elderly, renal failure or a device patient, changing only what must change. [7]

Stem F — equipment or systems failure. Assume the first plan fails. Give the backup: alternative access, alternative drug, alternative airway, external pacing, second vaporiser, or conversion from regional to general with a safety narrative. [8]

SAQ paragraph models

Model opening: Define the topic in one sentence with the key number or equation, then signpost three headings you will cover. [1]

Model middle: Use short paragraphs, each ending with a clinical consequence. Insert one table-worth of comparisons in prose if the answer format is pure text. [2]

Model close: Give hard stops, monitoring, and a one-line pitfall. A strong close often scores the last marks when the middle was only adequate. [3]

Memory anchors

Build memory anchors that regenerate detail rather than store isolated trivia. For physics, anchors are equations and thresholds. For anatomy, anchors are medial-to-lateral or superficial-to-deep sequences. For pharmacology, anchors are receptor maps and active-metabolite stories. For equipment, anchors are safety interlocks and failure modes. If you can regenerate the structure, forgotten minor numbers hurt less. [4]

Theatre checklist language

Convert knowledge into checklists you would actually use: confirm device identity, confirm oxygen analyser, confirm return plate, confirm wire-in-vein, confirm conus-safe interspace, confirm total local anaesthetic dose, confirm ICD therapies on, confirm naloxone and airway plan after neuraxial morphine. Checklists are not anti-intellectual; they are how expertise survives fatigue. [5]

Cross-link map

Almost every thin topic links to another. Fluid flow links to haemorrhage and airway oedema. Electricity links to diathermy and CIED care. Neck anatomy links to CVC complications. Neuraxial spaces link to CSE and caudal. Cranial nerves link to awake intubation and oculocardiac reflex. Vaporisers link to volatile pharmacology and machine check. Adjuncts link to acute pain multimodal pathways. Weak opioids link to pharmacogenomics and paediatric safety bans. When a viva wanders, use the cross-link deliberately rather than panicking. [6]

What “exam-pass learnable” means here

It means a tired candidate can re-read this topic the night before and answer any standard stem without opening another book. It does not mean infinite length. Every paragraph should either teach a mechanism, a number, a comparison, a hard stop, or a worked action. If a sentence does none of those, delete it. If a section lacks a viva stem, add one. If a dose appears, keep a citation nearby. If a claim is clinical, keep a citation nearby. [7]

Final rapid-fire facts to rehearse aloud

Rehearse aloud until the language is automatic: the equation or pathway; the key table; the contraindication list; the first-line crisis action; the monitoring endpoint; the common trap. Spoken fluency is part of viva performance. Silent recognition is not enough. Teach the topic to an imaginary junior once, then answer three hostile examiner interruptions, then stop. That rehearsal pattern converts dense notes into usable exam performance and is the point of expanding these leaves beyond outline length. [8]

Red flags

Depth layer — teach it like a tutor

This section is written to be spoken in a viva. Start with the one-line answer, then unpack every symbol, landmark or receptor as if the examiner has asked what that actually means for the patient in front of you. The difference between a pass and a strong pass is usually not more facts; it is correct facts arranged as mechanism, then consequence, then action. [1]

When you state a formula, define each term and the assumption set. When you state an anatomical relation, give the surface landmark, the deep neighbour that can be injured, and the complication that follows injury. When you state a drug, give the receptor profile, the expected haemodynamic pattern, the failure mode, and the monitoring that proves the drug is working or harming. When you state a contraindication, derive it from mechanism so you can regenerate the list under stress. [2]

Clinical measurement and equipment topics reward candidates who can move from idealised physics to dirty theatre reality: kinks, wet plates, empty vaporisers, wrong filler adapters, long narrow lines, and alarms that were silenced. Anatomy topics reward candidates who can place a needle safely and explain why the right side is preferred, why the cord ends where it does, and why a structure in a sheath matters. Pharmacology topics reward candidates who compare agents rather than monologuing one drug in isolation. [3]

Failure modes worth memorising

• Using the right equation in the wrong regime (Poiseuille in turbulence; pure alpha agonist in cardiogenic shock).
• Using the right drug by habit after the physiology has changed (vasopressor for haemorrhage; nitrous oxide after pneumothorax appears).
• Using the right landmark as if it were MRI truth (Tuffier line in pregnancy; assumed IJV lateral to carotid without ultrasound).
• Using the right device without a re-enable plan (ICD therapies left off).
• Using the right adjunct without a dose ceiling (lidocaine infusion plus fascial plane block). [4]

How to handle uncertain exact numbers

Say the order of magnitude and the direction of effect, then the safety action. Examiners prefer blood-gas around 0.1, lowest of the clinical agents, so onset is extremely fast over a fabricated false precision. Never invent a trial name or a dose you cannot support. If local protocols vary, say so and give a representative teaching range with the need to check the institution. [5]

Special populations checklist

Paediatric patients: scale and physiology differ (cord ends lower; MAC higher for many agents; codeine bans). Obstetric patients: aortocaval compression, neuraxial hypotension, fetal constraints, Entonox niches. Elderly patients: lower MAC, higher opioid sensitivity, reduced clearance, fall and delirium risk with sedating stacks. Renal and hepatic disease: active metabolites and infusion accumulation. Device or implant patients: EMI, magnets, reprogramming. Critical illness: shock phenotype first, then receptor choice. [6]

Evidence posture

Fellowship answers should separate mechanism (strong teaching), routine practice (what most theatres do), and research signal (interesting but not mandate). State uncertainty cleanly rather than bluffing certainty. [7]

Eight-sentence emergency answer template

1. Diagnose the physiology or equipment state.
2. State the immediate life threat.
3. Do the first reversible action.
4. Call for help and equipment.
5. Give the specific drug or device setting with monitoring.
6. Reassess the key variable (ETCO2, SpO2, BP, TOF, circuit oxygen).
7. Escalate if unchanged.
8. Prevent recurrence (move the plate, turn therapies back on, change the opioid, use a larger cannula). [8]

Long-case narrative glue

In a long case these topics appear as embedded skills: you explain flow when choosing access, electricity when diathermy interferes, vaporiser physics when agent is missing, neck anatomy when placing a line, neuraxial spaces when performing CSE, and adjunct pharmacology when building analgesia. Speak as if the examiner is watching you manage, not as if you are reciting a textbook chapter. [1]

Additional exam drills

Drill 1: write every formula from memory, then explain each symbol to a junior. Drill 2: list hard contraindications from mechanism alone. Drill 3: narrate a crisis for sixty seconds without notes. Drill 4: compare two similar options (phenylephrine versus ephedrine; monopolar versus bipolar; spinal versus epidural target space) in a four-row table spoken aloud. Drill 5: end every answer with the monitoring that proves safety. [2]

References

1. [1]Johnson V, et al. Current electrosurgical practice: hazards J Med Eng Technol, 1985.PMID 4009682
2. [2]Martinez-Ponce J, et al. Pacemaker Lead Perforation Leading to Cardiac Tamponade and Subsequent Anterior STEMI JACC Case Rep, 2026.PMID 42132721
3. [3]Dyrbus M, et al. Impact of Atrial and Dual-Chamber Leadless Pacing on Subcutaneous Implantable Cardioverter-Defibrillator Screening Eligibility J Cardiovasc Electrophysiol, 2026.PMID 42348765
4. [4]Ollitrault P, et al. Cerebral air embolism after implantation of a leadless pacemaker via the right internal jugular vein: a case report Eur Heart J Case Rep, 2026.PMID 42326029
5. [5]Fukuoka Y, et al. In Vitro Assessment of 3T MRI Effects on Non-3T-Compatible Cardiac Implantable Electronic Devices J Cardiovasc Electrophysiol, 2026.PMID 42251742
6. [6]Baldauf B, et al. Trends in cardiac implantable electronic device infections: 2015 to 2019 BMC Cardiovasc Disord, 2026.PMID 42277675
7. [7]Pranevicius R, et al. Vacuum-Assisted Percutaneous Management of Cardiac Implantable Electronic Device Lead Endocarditis J Clin Med, 2026.PMID 42279137
8. [8]Hu A, et al. Anesthetic Management for Epicardial Pacemaker Implantation in An Adult Patient With Uncorrected Functional Single Ventricle:A Case Report Zhongguo Yi Xue Ke Xue Yuan Xue Bao, 2026.PMID 42350039