PR19: Transcutaneous Pacing
- Symptomatic bradycardia unresponsive to atropine and epinephrine infusions
Paramedics should be aware of the distinction between pacing modes: demand pacing paces only when the patient’s intrinsic heart beat is less than a specified threshold, while non-demand paces at a set rate regardless of intrinsic activity. The monitor/defibrillator only detects electrical activity: under some circumstances, patients may have electrical activity that exceeds the pacing threshold but no mechanical output. In these cases, the patient will not be paced if the monitor is in demand mode. BCEHS monitor/defibrillators default to demand mode and, in general, should not be operated in non-demand mode.
- Transcutaneous pacing requires placement of limb leads and therapy electrodes. Ensure that limb leads are on and connected to the LifePak 15.
- Position therapy electrodes. Either anterior-lateral or anterior-posterior electrode placement is acceptable.
- Consider the need for sedation. Pacing is painful and patients who are conscious will require sedation and analgesia. Ketamine is the preferred agent in this case.
- Enable pacing mode on the LifePak by pushing the “Pacing” button. The monitor will prompt for a rate (the default is 60 BPM) and a current (the default is 0 mA).
- Slowly increase the current using the selector wheel until electrical capture is identified.
- Confirm a mechanical output with each captured paced beat. Femoral pulses may be more useful as they are further away from the muscle groups being stimulated by the pacemaker. If mechanical output is confirmed, add 10% to the current setting.
- Reassess blood pressure and clinical status. If the patient remains hypotensive despite effective pacing, consider increasing the rate.
- When conducting handovers of pacing-dependent patients at hospitals, clear communication and coordination of the transfer of pacemaking equipment is critical. Do not disconnect monitor components, including limb leads, until hospital staff confirms the patient is attached to their equipment and ready to take over pacing.
- Never attempt to resolve tachydysrhythmias using non-demand or “overdrive” pacing.
- When using non-demand pacing, there is a risk of causing an R-on-T event resulting in ventricular fibrillation or ventricular tachycardia, as the monitor will deliver pacing impulses regardless of intrinsic electrical activity. In situations where the patient is bradycardic but has electrical activity that exceeds the rate limit for demand pacing, CliniCall consultation is recommended to discuss care planning options, which may include higher pacing rates or pharmacological therapy.