
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
Contraindications
Patient information and 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:
- An IV line
- Continuous monitoring attached
- Oxygen if indicated
- 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:
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.
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.