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Transvenous Pacing

We've chosen to highlight this procedure as it is, on paper, very straightforward, but in reality (as noted by several practitioners we've talked with), it can be filled with tons of confusing variables and details. True, one could always hit the "EMERGENCY" button when in doubt but we're smart enough to understand this on a more sophisticated level. Despite the haters out there, the evidence is clear that we can insert these just as efficiently and successfully as our colleagues up in the cath lab.

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  Back to Basics: Transvenous Pacing

Transvenous pacing made (kinda) easy...

 Transvenous Pacing

Let's say you're in a small shop at about 2 AM. You've got your feet up and you're reading the Sunday Funnies. Suddenly, EMS comes rolling in with a patient with crushing chest pain. Your EKG is done immediately, and while it does not show a STEMI, let's say it shows complete heart block with the rate somewhere in the upper 30's. Your local interventionalist/EP is aware and is en route in his Maserati but it's going to be a good 20-30 minutes before he'll arrive. You briefly consider transcutaneous pacing, but when you look back at your nice, cooperative, conscious patient and realize that deep down in your soul you're just not that cruel.

Articles of Interest

Critical Care Device Series: Transvenous Pacemaker

Bradyarrhythmias caused by sinus node dysfunction and atrioventricular (AV) blocks are more common in patients in ages 70s-80s, and up to 20% of the patients presenting with bradycardia may need a temporary transvenous pacemaker for initial stabilization.

EMCrit 310 – Transvenous Pacemakers

20 >> 15 >> 10 >> 5 >> 3 >> 2 >> 1 >> Deflate >> Have them Cough (Pre-Covid) = Win (2.5-3x threshold). Really want to be < 1 mA threshold.

Emergency Transvenous Cardiac Pacing

Used for unstable bradycardia when other measures fail: --Medical treatment is inadequate (e.g.: atropine, treatment of hyperkalemia, reperfusion for ischemia, etc.) --External (transcutaneous) pacing fails to achieve capture, even after optimal placement and high output, or when not tolerated by the patient --Even if transcutaneous pacing succeeds, it is usually not a good solution for multiple hours and may not be persistently efficacious. --Often utilized in the setting of high grade AV node block, Sick Sinus Syndrome, etc.

Emergent Cardiac Pacing

This is done in same way that you insert a central line. If you are not already supremely comfortable placing central lines, placing a transvenous pacemaker is probably not a procedure for you.

Identifying Complete Heart Block and the use of Temporary Cardiac Pacing in the Emergency Department

There are no absolute contraindications to transvenous pacing. However, some relative contraindications to transvenous pacing include: patients with mild or rare intermittent symptoms with a stable escape rhythm, patients with prosthetic tricuspid valves, and patients with myocardial infarctions who are receiving thrombolytic agents or aggressive anti-platelet therapy.

Procedures » Transvenous Pacing

Place central venous access (Right IJ and left subclavian are preferred access routes as they have the straightest route to the heart, however left subclavian many times used for permanent pacemaker so try to stay away from)

Temporary Cardiac Pacing

Turn the mA down until you no longer have capture … that is your stimulation threshold .. then set the mA at double or triple that number.

Temporary Transvenous Cardiac Pacing

supine and head down, U/S guided or landmarks (apex of sternomastoid sternal and clavicular heads), insert sheath.

Temporary Transvenous Pacemaker Placement in the Emergency Department

Whereas consideration of temporary cardiac pacing may begin early in the course of patient management in the ED—depending upon patient stability—placement of a transvenous cardiac pacemaker (TVP) usually is performed after other less invasive means of treatment (e.g., pharmacologic, treating the underlying cause, transcutaneous pacing) have been explored and exhausted.

Transvenous Pacemaker Placement

Place sheath introducer as you would place a Cordis type of central line, confirm venous placement with ultrasound and suture in place.Preferred site: Right internal jugular. Secondary site: Left subclavian (Try to save this for permanent pacemaker if possible.)

Transvenous Pacemaker Placement

WHEN TO TRANSVENOUSLY PACE - Transcutaneous pacing worked so well, the hemodynamically unstable patient is now mentating and screaming from the electrical shocks. It’s never ideal to have to place a patient on pressors to compensate for sedation...

Transvenous Pacemaker Placement - Part 1: The Walkthrough

Site selection: Preferred sites are right IJ and left subclavian. These have the most direct anatomical route for the catheter to pass and successfully land in the RV. The right IJ is generally the most preferred as it saves the left subclavian for a permanent pacer. The left IJ or right subclavian can also be used. However, these approaches require the catheter to go through a tortuous course and make an acute angle turn respectively, making these more difficult locations for blind insertion. The right IJ and left subclavian have been shown to be successful sites even during ongoing CPR.