Pacing After ROSC: Not Recommended
Electric pacing is not recommended for routine use in cardiac arrest or after ROSC, as existing evidence shows it does not improve likelihood of ROSC or survival outcomes regardless of timing, location, or cardiac rhythm. 1
Evidence Against Pacing in Cardiac Arrest
The 2010 American Heart Association guidelines provide clear guidance based on comprehensive evidence review:
Pacing by any method (transcutaneous, transvenous, or transmyocardial) does not improve ROSC or survival when used during cardiac arrest, regardless of whether it is administered early or delayed in established asystole 1
No survival benefit has been observed from pacing in cardiac arrest across multiple studies examining different arrest locations (in-hospital or out-of-hospital) and primary cardiac rhythms (asystole, PEA) 1
The recommendation is Class III, Level of Evidence B, meaning pacing is not recommended and may be harmful 1
Historical Context: Fist Pacing
The evidence for percussion or fist pacing is even more limited:
Fist pacing is not recommended for patients in cardiac arrest 1
Evidence consists only of single-patient case reports and one moderate-sized case series with mixed asystole and bradycardia, with little support for its effectiveness, particularly when the effect cannot be confirmed by continuous ECG monitoring and pulse assessment 1
When Pacing May Be Considered (Pre-Arrest Only)
Transcutaneous pacing has a role before cardiac arrest occurs, not after ROSC:
For witnessed, monitored bradyarrhythmias with hemodynamic instability that have not yet progressed to cardiac arrest, transcutaneous pacing may be indicated 2
This is particularly helpful in reversible conditions like digoxin toxicity or atrioventricular block in inferior wall MI, or when transvenous pacing is not immediately available 2
Most patients with minimal hemodynamic compromise require 40-80 mA current, with higher thresholds in emphysema, pericardial effusion, or positive pressure ventilation 2
Post-ROSC Priorities (Not Pacing)
After ROSC is achieved, focus should shift to:
Airway management: Provide 1 breath every 6 seconds (10 breaths/min) with continuous monitoring via waveform capnography 3
Hemodynamic optimization: Maintain mean arterial pressure near the patient's normal level, as autoregulation may be impaired 1
Targeted temperature management: Consider therapeutic hypothermia or strict normothermia 3
Emergency cardiac catheterization: For suspected cardiac etiology, especially with ST elevation 1
Critical Pitfall to Avoid
Do not delay other critical post-ROSC interventions (treating reversible causes, considering coronary intervention for STEMI, optimizing ventilation and hemodynamics) by attempting pacing, which has no proven benefit 3