From the Guidelines
Transcutaneous pacing is recommended for patients with severe symptoms or hemodynamic compromise due to bradycardia, as it may be considered to increase heart rate and improve symptoms until a temporary transvenous or permanent pacemaker is placed or the bradycardia resolves 1.
Protocol for Transcutaneous Pacing
To perform transcutaneous pacing, first ensure the patient is connected to cardiac monitoring and has IV access.
- Place the anterior pad to the left of the sternum at the 4th-5th intercostal space, and the posterior pad behind the heart between the spine and left scapula.
- After connecting the pads to the external pacemaker, set the pacing rate typically between 60-80 beats per minute.
- Begin with a low output (usually 20-30 mA) and gradually increase by 5-10 mA until electrical capture is achieved, indicated by a wide QRS complex after each pacing spike on the ECG.
- Confirm mechanical capture by checking for a corresponding pulse and improved vital signs.
Important Considerations
- Sedation and analgesia (such as midazolam 1-2 mg IV and fentanyl 25-50 mcg IV) are often necessary as the procedure can be painful 1.
- This technique serves as a temporary bridge until a more definitive treatment like transvenous pacing can be established, and is effective because the electrical current causes myocardial depolarization, triggering ventricular contraction when the heart's natural pacemaker is failing.
Indications and Contraindications
- Transcutaneous pacing is indicated for patients with severe symptoms or hemodynamic compromise due to bradycardia, as it may be considered to increase heart rate and improve symptoms until a temporary transvenous or permanent pacemaker is placed or the bradycardia resolves 1.
- It is not recommended for patients with minimal and/or infrequent symptoms without hemodynamic compromise, as temporary transcutaneous or transvenous pacing should not be performed in these cases 1.
From the Research
Protocol for Transcutaneous Pacing in Treating Bradycardia
The protocol for transcutaneous (temporary) pacing in treating bradycardia involves several key steps and considerations, as outlined in the following points:
- Transcutaneous cardiac pacing is a temporary method of pacing that may be indicated in patients with severe symptomatic or hemodynamically unstable bradyarrhythmias 2.
- The goal of transcutaneous pacing is to support the patient's hemodynamics and re-establish perfusion, particularly in cases of bradycardia with inadequate perfusion or asystole 3.
- Proper skin preparation and electrode positioning are essential to ensure successful capture in most situations 2.
- Most patients with minimal hemodynamic compromise require a current of 40 to 80 mA, although pacing thresholds may be higher in patients with certain conditions, such as emphysema or pericardial effusion 2.
- Successful capture is usually characterized by a widened QRS complex, followed by a distinct ST segment and broad T wave on electrocardiography, and must be confirmed by assessing the patient's arterial pulse 2.
- Adequate sedation and analgesia are essential in ensuring patient comfort during the procedure 2.
- Transcutaneous pacing has been shown to be a clinically effective treatment modality in patients with atropine-resistant unstable bradycardia, with significant improvements in vital signs and electrocardiography 4.
Indications and Contraindications
The indications for transcutaneous pacing include:
- Severe symptomatic or hemodynamically unstable bradyarrhythmias 2
- Bradycardia with inadequate perfusion or asystole 3
- Reversible or transient conditions, such as digoxin toxicity and atrioventricular block in the setting of inferior wall myocardial infarction 2 The contraindications for transcutaneous pacing are not explicitly stated in the provided evidence, but it is noted that transvenous pacing may be preferred in certain situations, such as when transcutaneous pacing is not immediately available or carries a high risk of complications 2.
Patient Selection and Monitoring
Patient selection for transcutaneous pacing involves identifying those with severe symptomatic or hemodynamically unstable bradyarrhythmias, as well as those with reversible or transient conditions 2. Monitoring during transcutaneous pacing includes: