Pacing in Cardiac Arrest Does Not Improve ROSC or Survival
Electric pacing by any method (transcutaneous, transvenous, or transmyocardial) is not recommended for routine use in cardiac arrest, as it does not improve return of spontaneous circulation (ROSC) or survival regardless of timing, location, or initial cardiac rhythm. 1, 2
Evidence Against Pacing in Cardiac Arrest
The evidence consistently demonstrates no benefit from pacing during cardiac arrest:
Four studies examining pacing efficacy found no improvement in ROSC or survival when pacing was used in cardiac arrest patients, whether out-of-hospital or in-hospital. 1
The timing of pacing initiation made no difference—neither early pacing nor delayed pacing in established asystole showed any benefit. 1
The initial cardiac rhythm did not matter—pacing was ineffective for both asystole and pulseless electrical activity (PEA). 1
The American Heart Association classifies routine pacing as Class III, Level of Evidence B, meaning it is not recommended and may be harmful. 1, 2
Limited Exception: Fist (Percussion) Pacing
While electric pacing is not recommended, there is a narrow exception for percussion pacing in very specific circumstances:
Fist pacing may be considered only in hemodynamically unstable bradyarrhythmias (not true cardiac arrest) until an electric pacemaker becomes available. 1, 3
Five case series support percussion pacing specifically for P-wave asystolic cardiac arrest/complete heart block with residual atrial activity, where sinus rhythm with a pulse was restored. 1, 3
Percussion pacing is NOT recommended for typical cardiac arrest resuscitation, as evidence is limited to case reports and small case series without demonstrated improvement in outcomes. 3
The technique involves delivering rhythmic, forceful blows with a closed fist at approximately 100 per minute over the left sternal border, but effectiveness cannot be confirmed without continuous ECG monitoring. 3
What Actually Works: Focus on Proven Interventions
Instead of pacing, prioritize interventions with demonstrated benefit:
High-quality chest compressions at 100-120 compressions per minute with depth of at least 2 inches remain the cornerstone of cardiac arrest management. 4
Early defibrillation for shockable rhythms (VF/pulseless VT) is critical for survival. 1
Identify and treat reversible causes using the 4 Hs and 4 Ts framework (Hypoxia, Hypovolemia, Hyper/hypokalemia, Hypothermia, Thrombosis, Tamponade, Tension pneumothorax, Toxins). 5
Post-ROSC Management (After Achieving ROSC)
Once ROSC is achieved, shift focus to post-resuscitation care:
Airway management: Provide 1 breath every 6 seconds (10 breaths/min) with continuous waveform capnography monitoring. 2
Hemodynamic optimization: Maintain mean arterial pressure near the patient's normal baseline, as autoregulation may be impaired. 2
Targeted temperature management: Consider therapeutic hypothermia (32-34°C for 12-24 hours) or strict normothermia for comatose patients. 1, 2
Emergency cardiac catheterization: Consider for suspected cardiac etiology, especially with ST-elevation on post-ROSC ECG. 2
Critical Pitfalls to Avoid
Never delay high-quality CPR or defibrillation to attempt pacing—these have no proven benefit and waste critical time. 2, 3
Do not confuse hemodynamically unstable bradycardia (where temporary pacing may help) with true pulseless cardiac arrest (where pacing does not work). 1, 3
Avoid delaying post-ROSC interventions such as treating reversible causes, coronary intervention for STEMI, or optimizing ventilation and hemodynamics. 2