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Transcutaneous Cardiac Pacing Periprocedural Care

  • Author: Ali A Sovari, MD, FACP; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Dec 17, 2014
 

Patient Education and Consent

Appropriately used, external cardiac pacing is associated with few complications. Skin burns, pain, discomfort, and failure to capture are the main limitations of this method. It is important to educate the patient about the procedure and especially about potential discomfort related to skin tingling and burning and associated skeletal muscle contractions. If time allows, obtain informed consent.

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Equipment

Equipment used in transcutaneous cardiac pacing includes the following:

  • Pacing unit
  • Cardiac monitor
  • Defibrillator (see the image below)
  • Pacing electrodes (pads)
    Defibrillator with pacing capability. Defibrillator with pacing capability.

Although some pacing units provide only pacing, most defibrillators provide both cardiac pacing and rhythm monitoring. Those units can usually deliver a current as high as 200 mA for as long as 40 ms. The stimulus current is usually delivered in a rectangular waveform, which has been shown to be associated with lower excitation thresholds than other impulse shapes.[13]

The size of the electrode pads usually ranges from 8-15 cm, and the pacing electrodes can be applied by medical personnel. Chest pressure can be applied and cardiopulmonary resuscitation performed by pressing on the pads. To record a clear electrocardiographic rhythm, the recording electrode should be placed as far as possible from the pacing pads (see Positioning).

External pacemakers

Transcutaneous pacing with external pacemakers is indicated as a temporizing measure for treatment of symptomatic bradycardias, including sinus bradycardias and atrioventricular (AV) nodal blocks; it may also be used prophylactically in patients with these rhythms who are maintaining a stable blood pressure. External transcutaneous pacing has been used successfully for overdrive pacing of tachyarrhythmias; however, it is not considered beneficial in the treatment of asystole.

Modern external pacemakers use longer pulse durations and larger electrodes than the early models did. These modifications allow administration of higher currents with less patient discomfort. Studies have demonstrated that more than 90% of patients tolerate pacing for 15 or more minutes. Modern devices are capable of delivering up to 140-200 mA tolerably.

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Patient Preparation

Anesthesia

Transcutaneous cardiac pacing may be associated with discomfort such as a burning sensation of the skin, skeletal muscle contractions, or both. Because of this, patients who are conscious and hemodynamically stable should be sedated with a drug, such as midazolam, before initiation of pacing (see Procedural Sedation).

The literature reports a wide range of sedation techniques and sedative agents. Combination sedation with benzodiazepines and narcotics appear to be in relatively broad use.[19]

Positioning

Before applying the pacing electrodes, wipe the patient’s skin with alcohol, and allow the area to dry. Without abrading the skin, carefully shave excessive body hair, which can elevate the pacing threshold and increase burning and discomfort.

Skin abrasions, the presence of a foreign body beneath the electrodes, sweating, and a high pacing threshold increase the patient’s pain and discomfort. Try to avoid abrading the skin when shaving excess hair, to remove a foreign body, to clean the skin, and to review and address the above-mentioned factors that may increase the pacing threshold.

The anterior electrode should have negative polarity and should be placed either over the cardiac apex or at the position of lead V3. If the positive electrode is placed anteriorly, the pacing threshold may increase significantly; this, in turn, increases the patient’s discomfort and may result in failure to capture.

The posterior electrode, which should be of positive polarity, should be placed inferior to the scapula or between the right or left scapula and the spine; it should not be placed over the scapula or the spine. Alternatively, the positive electrode can be placed anteriorly on the right upper part of the chest (see the image below). The latter configuration does not affect the pacing threshold.[12]

Pacing electrode pads of external pacing unit and Pacing electrode pads of external pacing unit and locations in which each pad should be placed.
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Contributor Information and Disclosures
Author

Ali A Sovari, MD, FACP Fellow in Clinical Cardiac Electrophysiology, Cedars Sinai Medical Center/Heart Institute

Ali A Sovari, MD, FACP is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Physician Scientists Association, American Physiological Society, Biophysical Society, Heart Rhythm Society, Society for Cardiovascular Magnetic Resonance

Disclosure: Nothing to disclose.

Coauthor(s)

Abraham G Kocheril, MD, FACC, FACP, FHRS Professor of Medicine, University of Illinois College of Medicine

Abraham G Kocheril, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Cardiology, Central Society for Clinical and Translational Research, Heart Failure Society of America, Cardiac Electrophysiology Society, American College of Physicians, American Heart Association, American Medical Association, Illinois State Medical Society

Disclosure: Nothing to disclose.

Ramin Assadi, MD Assistant Professor of Medicine, Division of Interventional Cardiology, Loma Linda University Medical Center

Ramin Assadi, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Acknowledgements

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
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  2. Trigano JA, Remond JM, Mourot F, Birkui P, Levy S. Left ventricular pressure measurement during noninvasive transcutaneous cardiac pacing. Pacing Clin Electrophysiol. 1989 Nov. 12(11):1717-9. [Medline].

  3. Feldman MD, Zoll PM, Aroesty JM, Gervino EV, Pasternak RC, McKay RG. Hemodynamic responses to noninvasive external cardiac pacing. Am J Med. 1988 Mar. 84(3 Pt 1):395-400. [Medline].

  4. Murdock DK, Moran JF, Speranza D, Loeb HS, Scanlon PJ. Augmentation of cardiac output by external cardiac pacing: pacemaker-induced CPR. Pacing Clin Electrophysiol. 1986 Jan. 9(1 Pt 1):127-9. [Medline].

  5. Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation. 2008 May 27. 117(21):e350-408. [Medline].

  6. Ho JD, Heegaard WG, Brunette DD. Successful transcutaneous pacing in 2 severely hypothermic patients. Ann Emerg Med. 2007 May. 49(5):678-81. [Medline].

  7. Sherbino J, Verbeek PR, MacDonald RD, Sawadsky BV, McDonald AC, Morrison LJ. Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a systematic review. Resuscitation. 2006 Aug. 70(2):193-200. [Medline].

  8. Schwartz B, Vermeulen MJ, Idestrup C, Datta P. Clinical variables associated with mortality in out-of-hospital patients with hemodynamically significant bradycardia. Acad Emerg Med. 2004 Jun. 11(6):656-61. [Medline].

  9. Rosenthal E, Thomas N, Quinn E, Chamberlain D, Vincent R. Transcutaneous pacing for cardiac emergencies. Pacing Clin Electrophysiol. 1988 Dec. 11(12):2160-7. [Medline].

  10. Im SH, Han MH, Kim SH, Kwon BJ. Transcutaneous temporary cardiac pacing in carotid stenting: noninvasive prevention of angioplasty-induced bradycardia and hypotension. J Endovasc Ther. 2008 Feb. 15(1):110-6. [Medline].

  11. Castle N, Porter C, Thompson B. Acute myocardial infarction complicated by ventricular standstill terminated by thrombolysis and transcutaneous pacing. Resuscitation. 2007 Sep. 74(3):559-62. [Medline].

  12. Sodeck GH, Domanovits H, Meron G, et al. Compromising bradycardia: management in the emergency department. Resuscitation. 2007 Apr. 73(1):96-102. [Medline].

  13. Jaworska K, Prochaczek F, Galecka J. Influence of the shape of the pacing pulse on ventricular excitation threshold and the function of skeletal muscles in the operating field during non-invasive transcutaneous cardiac pacing under general anaesthesia. Cardiol J. 2007. 14(2):137-42. [Medline].

  14. Zoll PM, Zoll RH, Falk RH, Clinton JE, Eitel DR, Antman EM. External noninvasive temporary cardiac pacing: clinical trials. Circulation. 1985 May. 71(5):937-44. [Medline].

  15. Falk RH, Zoll PM, Zoll RH. Safety and efficacy of noninvasive cardiac pacing. A preliminary report. N Engl J Med. 1983 Nov 10. 309(19):1166-8. [Medline].

  16. Holger JS, Minnigan HJ, Lamon RP, Gornick CC. The utility of ultrasound to determine ventricular capture in external cardiac pacing. Am J Emerg Med. 2001 Mar. 19(2):134-6. [Medline].

  17. Ettin D, Cook T. Using ultrasound to determine external pacer capture. J Emerg Med. 1999 Nov-Dec. 17(6):1007-9. [Medline].

  18. Trigano AJ, Azoulay A, Rochdi M, Campillo A. Electromagnetic interference of external pacemakers by walkie-talkies and digital cellular phones: experimental study. Pacing Clin Electrophysiol. 1999 Apr. 22(4 Pt 1):588-93. [Medline].

  19. Thomas SP, Thakkar J, Kovoor P, Thiagalingam A, Ross DL. Sedation for electrophysiological procedures. Pacing Clin Electrophysiol. 2014 Jun. 37(6):781-90. [Medline].

  20. Pecha S, Aydin MA, Yildirim Y, et al. Transcutaneous lead implantation connected to an externalized pacemaker in patients with implantable cardiac defibrillator/pacemaker infection and pacemaker dependency. Europace. 2013 Aug. 15(8):1205-9. [Medline].

 
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Normal action potential of myocyte and main ion channels that play major roles in different phases of action potential.
Defibrillator with pacing capability.
Pacing electrode pads of external pacing unit and locations in which each pad should be placed.
Rhythm strip showing failure to capture in first 4 pacing stimuli that did not produce any pulse. When capture occurred, each pacing artifact is followed by QRS complex (albeit bizarrely shaped) and pulse.
Transcutaneous cardiac pacing in a patient with third-degree heart block. Video courtesy of Therese Canares, MD; Marleny Franco, MD; and Jonathan Valente, MD (Rhode Island Hospital, Brown University).
 
 
 
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