# Transcutaneous Pacing

## Overview

This module describes transcutaneous pacing, a temporary, non-invasive form of pacing, with two modes. Demand pacing is used whenever possible, and delivers pacing shocks only when required. Fixed pacing is used when R waves are not identifiable, and delivers pacing shocks at a fixed rate regardless of the patient’s heart rate.

## Indications

1. Unstable adults with bradyarrhythmia (<50 bpm), who have failed medical management

2. Unstable children with bradyarrhythmia (<60 bpm), who have failed medical management

## Contraindications

1. None

## Patient information & consent

This procedure can be painful for patients, but some may be hemodynamically unstable and it may not be safe to give them analgesia. Continuous reassurance is important.

### How do I explain this procedure?

“Your heart is beating too slowly and it’s making you very unwell. I need to boost your heart by giving you mild electrical shocks, which acts like medicine for the heart and will help the beat get back to normal.”

### What can my patient expect?

“Pacing can be uncomfortable or painful. I will stick pads to your chest where the electricity will come from, and as soon as it is safe I will give you pain medication to help with the discomfort. These shocks are very small and will not harm any part of your body.”

### What is my patient’s role?

“I need you to tell me if you are in pain, and I will continuously explain to you everything that I do. Please try and stay calm.”

## Preparation

Follow the Bradycardia Management algorithm to this point. The patient should have:

1. An IV line
2. Continuous monitoring attached
3. Oxygen if indicated
4. Procedural sedation or analgesia only if haemodynamically safe

If a child is presenting with bradycardia and is clinically unstable, it is unlikely of cardiac origin requiring transcutaneous pacing. Consult your senior for advice or assistance, and consult the pediatric bradycardia algorithm.

Transcutaneous pacing is an emergency procedure. Always:

1. Know where defibrillators, transcutaneous pads, and red trolleys are kept. Know the relevant staff and keep your seniors’ contact details close at hand.

2. Familiarise yourself with the defibrillators in your work area. Check that they are maintained regularly and have pads and the correct connections.

3. Keep unstable patients in resuscitation bays with continuous monitoring.

## Site & Positioning

The patient should be lying flat on their back or seated comfortably in a bed with their chest exposed. All clothes, including undergarments, should be removed from the chest.

## Procedure

Follow medical asepsis with non-sterile gloves.

1. Switch On the defibrillator to the manual defibrillation mode.

2. Attach the three monitoring leads.

3. Attach pacing pads at the right second intercostal space and the left midaxillary line near the apex of the heart.

4. If the defibrillator is not already on Lead II, press the Lead Select mode button until it shows Lead II.

5. Press the Pacer button.

6. Set the Rate to 60-80 bpm, and the Output to 70 mA.

7. Press the Start button to start pacing.

8. Dial up the Output by 5-10 mA at a time until you achieve electrical and mechanical

   capture
   capture

   Electrical capture: a QRS complex with T wave appears after every pacer spike.

   Mechanical capture: pacing results in palpable peripheral pulses and clinical signs of improved perfusion.

   and, then add 5-10 mA more.

9. The patient’s discomfort will increase as their haemodynamic status improves. Reassess regularly for analgesic requirements.

10. Record the completion of the procedure in patient notes.

11. Refer to cardiology for definitive treatment.

## Troubleshooting

The patient has a lot of breast tissue.

Always try to place pads under or lateral to breasts. Large breasts can compromise the effectiveness of the shock delivered.

My patient is soaking wet.

Wipe the patient down quickly before applying pads.

My patient is so hairy I can’t get contact with the skin.

Use a razor to shave the contact areas, or use any kind of adhesive dressing or pads to “wax” off the worst of the body hair.

My patient is wearing an underwire bra.

Cut it off. The current can run through the underwires, rendering it ineffective, and can cause burns.

My patient has a medication patch on their chest.

Remove it and wipe the area quickly.

My patient has an implanted pacemaker or defibrillator.

Don’t be deterred, but avoid placing your pads on the device.

The screen keeps showing asystole.

Press the Gain button several times to enlarge the ECG displayed. You may have a very low amplitude rhythm you just can’t see at the current level of gain.

I struggle to remember where to place each of the three leads.

“Red on the right, green on the spleen, and what’s left on the left.” Place the red electrode on the right shoulder, yellow electrode on the left shoulder, and green electrode on the lower left torso.

I need to pace an adult but I only have child pads.

It is acceptable to use adult pads on children, but child and infant pads cannot be used on adults.

## Risks

1. Rhythm conversion to a pulseless rhythm

2. Burns & electrical injuries to patient

3. Burns & electrical injuries to healthcare providers

4. Explosions and medical fires due to oxygen exposure (It is safe to use oxygen mask with transcutaneous pacing)

## References

1. Self M, Tainter CR. Overdrive Pacing. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549874/

2. Resuscitation Council of Southern Africa. Bradycardia Management Algorithm. 2021.