What are the steps to pace a patient from applying chest pads onwards according to Canadian guidelines?

Transcutaneous Cardiac Pacing: Step-by-Step Procedure from Pad Application

For transcutaneous cardiac pacing, place adult-sized electrode pads (8-12 cm diameter) in an anterior-lateral position on the exposed chest, with the anterior pad on the left anterior chest avoiding breast tissue, then initiate pacing at the appropriate settings. 1

Pre-Application Chest Preparation

Before applying pads, rapidly address any barriers to effective pad contact:

• Quickly wipe the chest dry if the patient is diaphoretic or has excess moisture, but do not delay pacing 1
• Remove any transdermal medication patches from pad placement sites, as they may block energy delivery and cause burns 2, 1
• Remove excessive chest hair only if it can be done rapidly by briskly pulling off an electrode pad or quick shaving, but minimize any delay in shock delivery 2, 1

Pad Placement

Standard Positioning

• Use adult-sized electrode pads (8-12 cm diameter) for adequate contact and lower transthoracic impedance 2, 1
• Place the anterior pad on the left anterior chest in the anterolateral position 1
• In large-breasted individuals, position the left electrode pad lateral to or underneath the left breast, avoiding breast tissue 2
• The anterolateral position is reasonable as the default for ease of placement 2

Alternative Positioning

• Anterior-posterior placement is an acceptable alternative to anterolateral positioning 2
• Both positions have similar efficacy, though anteroposterior may maximize transmyocardial current 2

Special Considerations for Implanted Devices

• Ensure pads are at least 8 cm away from any implanted pacemaker or ICD device if present 2, 1
• Position pads perpendicular to the major axis of any cardiac rhythm management device when possible 2
• Do not place pads directly over the pulse generator 2

Initiating Pacing

Once pads are properly applied:

• Connect the pads to the transcutaneous pacemaker unit 1
• Set the pacing rate according to clinical indication (typically 60-80 bpm for bradycardia)
• Gradually increase the output (mA) until electrical capture is achieved, typically starting around 40-50 mA and increasing as needed 3
• Confirm mechanical capture by palpating a pulse corresponding to each paced beat
• Provide analgesia/sedation as transcutaneous pacing can be uncomfortable for conscious patients

Critical Pitfalls to Avoid

• Do not use transcutaneous pacing as routine treatment in cardiac arrest with asystole or pulseless electrical activity (PEA), as it shows no benefit regardless of timing, location, or primary rhythm 1
• Do not delay pacing for perfect chest preparation—rapid initiation is more important than removing every hair or achieving a completely dry chest 2, 1
• Do not place pads over medication patches, as this can cause electrical arcing and burns 2, 4
• Avoid placing pads too close to implanted devices (maintain 8 cm distance) to prevent device malfunction 2, 1

Monitoring After Initiation

• Continuously monitor cardiac rate and rhythm 2
• Verify both electrical and mechanical capture with each adjustment
• Have backup pacing equipment immediately available 2
• Reassess pad position if capture is lost or requires unexpectedly high output