CARDIAC PACING

Question 1

TRANSCUTANEOUS PACING

Answer 1

INDICATIONS
Symptomatic bradycardia unresponsive to medical therapy or at risk for decompensation
Overdrive pacing of tachydysrhythmias

CONTRAINDICATIONS
Asystole
Mechanical tricuspid valve
Profound hypothermia

EQUIPMENT
Potable pulse generator / defibrillator
Pacer Pads

METHOD
cardiac monitor and continuous pulse oximetry.

If time permits, administer sedative and analgesic:

Midazolam
Dose: 0.05-0.1 mg/kg slow IV push
Repeat q 3-5 minutes PRN.

Fentanyl
Dose: 0.25-1 µg/kg slow IV push
Repeat q 15-20 minutes PRN.

Ketamine
Dose: 0.1-0.3 mg/kg IV slow push or infusion over 15-30 minutes.
(subdissociative dose)
OR
0.05-0.25 mg/kg/hour infusion if needed

Attach transcutaneous pacer pads (anterior-posterior placement is preferred)

Connect the portable pulse generator/defibrillator monitor leads to the patient.

Turn on pacing mode.

Set rate to 80 beats/minute.

Increase output until there is capture (for an average-size adult, start with 40 mA).

The patient’s chest wall muscle will contract at the set rate.

Confirm mechanical capture with pulse oximetry or distal pulse (avoid carotid pulse because of the rhythmic chest wall contraction).

Decrease output until capture is lost, and then set the output to 5 mA above that threshold.

Request transvenous pacing set up (see transvenous pacing equipment).