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Transcutaneous Pacing

When do we perform Transcutaneous pacing?

• Symptomatic clinically significant bradycardias Don't just treat a number. Treat those bradycardias associated with hypotension, pulmonary edema, or evidence of decreased cerebral perfusion that is unresponsive to initial first line measure
• Initiate TCP while searching for correctable causes and concomitantly administering other therapies (i.e. fluids, atropine, digibind, glucagon, high dose insulin)
• Three common causes of bradycardia in the emergency department include drugs (specifically overdoses) hyperkalemia, and myocardial ischemia

   

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 Emergent Cardiac Pacing

The amount of energy used to pace is less than 1/1000 of that used to defibrillate. There is little risk of injury to clinicians and, if necessary, chest compression can be done directly over the pads while pacing.

 Management in ED

Best capture is obtained with anterior/posterior... The positive pad is placed posteriorly to the left of the spine, beneath the left scapula. The negative pad is placed anteriorly between the xiphoid process and the left nipple. A second option is to place both pads anteriorly with positive electrode to the right of the sternum and negative electrode at V6 position. The initial pacing rate should be set to 80 bpm with the current set to 30 mA. The current can be increased by 10 mA at a time until capture is noted by a QRS complex and T wave following each pacemaker spike. A pulse can be appreciated when a perfusing rhythm is achieved. Adjust the current to 5-10 mA above capture threshold to ensure continued capture, this typically occurs somewhere between 50-100 mA.

 Non-invasive Temporary Pacing

Non-invasive temporary pacing (NTP), an accepted emergency intervention since 1982, has been shown to be safe and effective over the ensuing years. It is considered to be a “tried and true” treatment modality, so little is written about it today.

 Therapeutics: Pacing Through Skin and Vein

Historically, it was taught to place pads at the anterolateral (AL) position with the positive electrode pad over the right upper anterior chest wall and the negative electrode over the left midaxillary line. This was generally the easiest placement as it did not involve rolling the unstable patient; however, new data has shown that anteroposterior (AP) placement may be more effective. AP placement is when the positive electrode is placed under the left scapula and the negative electrode pad is placed over the left parasternal chest wall. AP placement was proven to be capture at a lower current than the AL placement in the same patients, thus more effective.

Articles of Interest

Bradycardia and Pacing

If pacing not immediately available or deemed inappropriate consider... Adrenaline infusion +/- 10-20mcg IV. The pacing is usually set to demand (as required) at 70-80 beats per minute starting low (eg. 30 mA) and increasing until electrical capture with established output occurs. In some settings (such as pre-hospital) where there is a concern that electrical artifact may inhibit pacing in the demand mode, it is reasonable to use a fixed (asynchronous) mode.

Mastering transcutaneous pacing

In this video, from our Emergency Procedures Masterclass course, you'll learn how to transcutaneously pace a patient and what to do if a patient doesn't achieve capture.

Pacing 101 Transcutaneous is Just Stupid

This podcast lays down the argument that transcutaneous pacing is stupid. Transcutaneous pacing is difficult – patients are diaphoretic, capture rates may be 40%, and it takes a significant amount of energy. Further, it hurts. However, in our opinion, there may be a role. In this talk, Dr. Bellezo quotes a 1981 study, in which emergent pacers were placed in “6 minutes.” Review of this study finds that this was actually 6 minutes, 45 seconds (closer to 7 minutes) [1]. This likely does not reflect the majority of emergency providers experience, certainly not ours, where the range is more often 15-30 minutes for the procedure. Thus, transcutaneous pacing may be a temporizing measure as one locates the ultrasound, gathers the supplies, and prepares for transvenous pacing in the unstable patient.

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.

Transcutaneous and Transvenous Cardiac Pacing

Since it was originally described in 1952 by Zoll for the treatment of asystole as well as of brady­­dysrhythmias, transcutaneous pacing has continued to be used in the emergency setting. This noninvasive method of cardiac pacing allows for expedient placement and initiation of therapy without the risks of an invasive procedure.

Transcutaneous Pacing – What’s the Best Pad Placement?

Placing transcutaneous cardiac pacer pads in the anteroposterior position required less energy to successfully capture.

Resources

StatPearls

Pacing pads are positioned on the patient's chest either in the anterolateral position of anteroposterior one. Multiple variations of pacer pad placement are equally effective.