An easy way to think of some of these causes are what we call the H’s & T’s. As such it is important to identify the contributing causes. Transcutaneous pacing is a temporary solution for bradyarrhythmias. Sedation medications such as Benzodiazepines, Opioids or Propofol can have a negative effect on blood pressure so it is not uncommon for healthcare providers to also consider the administration of Epinephrine or Dopamine infusions in conjunction with sedation to prepare for transcutaneous pacing. In a truly unstable patient, it is not uncommon for the patient to be hypotensive. Often times 50-100 mA are required for adequate pacing and the Ideal current is 1.25x what was required for capture. Most patients cannot tolerate currents of 50 milliamps and higher without sedation. Patients’ Response to Levels of Output or Milliamperes Output (mA)Īs you can see in the chart above, transcutaneous pacing can be painful especially as the output is increased. Effective pacing should produce an increase in blood pressure and level of consciousness but the patient should be monitored closely as the pacemaker can malfunction. Generally, about 2 milliamperes above the initial electrical capture is sufficient. Once electrical capture is achieved, adjust the pacing output or milliamperes just slightly above the level in which electrical capture was achieved. Mechanical capture can be assessed by checking the pulses on the patient’s right upper extremity or right femoral pulse. You will increase the current slow and steady until electrical capture is achieved which is represented by a wide QRS and broad T wave. Next the output or milliamperes needs to be adjusted and set. Normally, the rate is set at a nonbradycardic rate between 60 and 80 beats per min. Next you will want to set the pacing rate. After placement of the pacing electrodes, connect the pacing cable to the electrodes and power on the device and set to “Pace” mode. Pads are On… Now What?īegin Transcutaneous pacing by connecting the patient to an ECG monitor to obtain a rhythm strip and confirm there is a rhythm which requires pacing. Additionally, if defibrillation is necessary with paddles, place the defibrillation paddles about 2-3 cm (3/4 – 1 in) away from the pacer electrodes to prevent arcing. The pads can also be placed in an anterior/lateral approach (figure A).Ī few key points to address for proper placement include ensuring the pads fit completely on the patient’s chest, have a minimum of 1-2 inches of space between electrodes and ensure no overlap or is that the electrodes are not placed on bony prominences of the sternum, spine, or scapula. The posterior (positive) electrode is place in the left posterior thorax directly behind the anterior electrode. Transcutaneous pacing involves attaching two pacing electrodes on the patient’s skin placed in an anterior/ posterior approach (Figure B) The anterior (negative) electrode is placed o to the left of the sternum, halfway between the xyphoid process and left nipple. Contraindications for Transcutaneous Pacingīradycardia in the setting of severe hypothermia Placement A study conducted in 2018 determined that out of two separate cohorts one comprised of 53 and 51 respectively, only 36% (18 participants) demonstrated they could effectively employ all 6 tasks during the study related to establishing effective transcutaneous pacing. Transcutaneous pacing can be extremely effective and is fairly quick to employ but due to the complexity of the devices it can be quite intimidating to use and learning barriers prevent rapid employment of this critical life saving tool. Pacing is also recommended for severely symptomatic patients, especially when the block is at or below the His-Purkinje level (ie, type II second-degree or third-degree AV block). Additional indications of transcutaneous pacing include symptomatic bradycardia, most commonly resulting from acute MI, sinus node dysfunction, and complete heart blocks. Transcutaneous pacing is a treatment option for symptomatic bradycardias unresponsive to Atropine or when Atropine is not immediately available.
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