What are the guidelines for transcutaneous pacing?

Transcutaneous Pacing Guidelines

Transcutaneous pacing is recommended as the first-line temporary pacing modality for symptomatic bradycardia unresponsive to medical therapy, particularly in emergency situations where immediate intervention is needed before more definitive therapy can be instituted. 1

Indications for Transcutaneous Pacing

Class I Indications (Strongly Recommended):

• Hemodynamically unstable patients with symptomatic bradycardia unresponsive to medical therapy 1
• Ventricular asystole 1
• Patients requiring temporary pacing while awaiting transvenous pacing or permanent pacemaker placement 1

Class II Indications (Reasonable to Consider):

• Sinus bradycardia (rate less than 50 bpm) with symptoms of hypotension (systolic blood pressure less than 80 mm Hg) unresponsive to drug therapy 1
• Symptomatic bradycardia not responsive to atropine 1
• Bilateral bundle branch block (alternating BBB or RBBB with alternating LAFB/LPFB) 1
• New or indeterminate age bifascicular block (RBBB with LAFB or LPFB, or LBBB) with first-degree AV block 1
• Mobitz type II second-degree AV block 1

Technical Considerations

Electrode Placement and Application:

• Apply transcutaneous pacing patches to clean, dry skin 2
• Anterior patch placement: left precordium (cardiac apex) 2
• Posterior patch placement: left infrascapular region or right anterior chest 2
• Ensure proper skin contact to minimize impedance 2, 3

Pacing Parameters:

• Initial output: Start at 40-80 mA and increase until consistent capture is achieved 2, 3
• Higher current may be required in patients with:
  • Emphysema
  • Pericardial effusion
  • Positive pressure ventilation 2
• Rate setting: Typically 60-80 beats per minute, adjusted based on clinical response 2, 3

Confirmation of Capture:

• Electrical capture: Widened QRS complex followed by distinct ST segment and broad T wave on ECG 2
• Mechanical capture: Must be confirmed by assessing arterial pulse or waveform 1, 2
• Consider alternative ECG leads if pacing artifact obscures QRS complex 1
• Use additional monitoring methods (arterial pressure, pulse oximetry) when ECG assessment is difficult 1

Patient Management

Pain Management:

• Transcutaneous pacing is associated with significant discomfort 1
• Provide adequate sedation and analgesia for conscious patients 2, 4
• Consider alternative pacing methods for prolonged pacing needs 1

Monitoring Requirements:

• Continuous cardiac monitoring until pacing is no longer necessary 1
• Regular assessment of capture threshold 2, 3
• Monitoring for complications including skin burns or tissue damage 4

Special Populations

Pediatric Considerations:

• Transcutaneous pacing is effective in children across all age groups 5
• Smaller electrode sizes may be necessary for children weighing less than 15 kg 5
• Mean threshold current requirements are similar to adults (approximately 50-60 mA) 5

Limitations and Complications

Limitations:

• Variable capture reliability, particularly in cardiac arrest situations 6
• Significant patient discomfort limiting prolonged use 1, 4
• Difficulty confirming mechanical capture due to large pacing artifact 1

Complications:

• Pain and discomfort 1, 4
• Skeletal muscle contraction 4
• Potential for skin burns with prolonged use 4

Transition to Definitive Therapy

• Transcutaneous pacing should be considered a bridge to more definitive therapy 1
• For patients likely to require prolonged pacing, transition to transvenous or permanent pacing is recommended 1
• Transcutaneous pacing is particularly valuable in patients receiving thrombolytic therapy, reducing the need for vascular interventions 1