**8. Transcutaneous pacing**

Transcutaneous pacing is a temporary means of pacing a patient's heart in an abnormally slow heart rate. It is accomplished by delivering pulses of electric current through the patient's chest, which stimulates the heart to contract in a minimally effective manner.

#### **8.1. Indications**

Indications for TCP can be grouped in bradyarrhythmias and tachyarrhythmias as follows:

#### *8.1.1. Bradyarrythmias*


#### *8.1.2. Tachyarrythmias*

Safety is a key concern in the performance of defibrillation. Any staff member acting as a ground for the electrical discharge can be seriously injured. The operator must announce "all clear" and give staff a chance to move away from the bed before discharging the

Care must be taken to clean up spills of saline or water, because they may create a conductive

• Harmless arrhythmias, such as atrial, ventricular, and junctional premature beats (commonest)

paddles.

**7.7. Complications**

path to a staff person at the bedside.

**Figure 14.** Defibrillation and cardioversion.

**Figure 13.** Defibrillation and cardioversion.

86 Essentials of Accident and Emergency Medicine

After the shock is delivered, continue the CPR.


• Prophylactically in cardiac catheterization, after open heart surgery and in cases of bradycardia-dependent tachycardias (e.g., torsades de pointes)

**Preparation**The process of electrical pacing can be of significant discomfort to the patient if

Resuscitation Procedures in Emergency Setting http://dx.doi.org/10.5772/intechopen.76165 89

Also, patient's skin should be wiped with alcohol and dried, any foreign body should be removed, and careful shaving of the excessive hair should be done, taking care to avoidabrading the skin as it can elevate the pacing threshold and increase burning and discomfort.

The electric pads can be placed either in anterolateral position or anteroposterior position. The anterior electrode should have negative polarity and should be placed at the cardiac apex

The positive or posterior electrode 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

To initiate TCP, after application of pads and activating the device, turn the selection knob to

Select the current, and look for one QRS complex after each pacing spike. This is called "electrical capture." Look for corresponding pulse by checking patient's pulse (**Figure 17**). If the pulse corresponds with the electrical capture along with improved BP and clinical status of

The electrical output should be started from maximum output if the patient is in cardiac arrest, and then decrease to keep 10–15 mA above the threshold to maintain adequate mechanical

**Figure 16.** Pacing electrode pads of external pacing unit and locations in which each pad should be placed.

the "pacer" mode, and select pacer rate of 60–80; as shown in **Figure1**.

the patient, "mechanical capture" is attained as shown in **Figure 3**.

It is, therefore, advised to consider analgesia or sedation to ease patient's discomfort.

not prepared adequately.

**8.2. Technique**

capture.

or at lead V3 position.

chest (see the image below) (**Figure 16**).

#### *8.1.3. Contraindications*

There are no absolute contraindications; however, it is advisable to avoid pacing in the following conditions:


#### *8.1.4. Equipment needed*

Equipment used in transcutaneous cardiac pacing includes the following (**Figure 15**):


**Figure 15.** Defibrillator with pacing capability.

**Preparation**The process of electrical pacing can be of significant discomfort to the patient if not prepared adequately.

It is, therefore, advised to consider analgesia or sedation to ease patient's discomfort.

Also, patient's skin should be wiped with alcohol and dried, any foreign body should be removed, and careful shaving of the excessive hair should be done, taking care to avoidabrading the skin as it can elevate the pacing threshold and increase burning and discomfort.

### **8.2. Technique**

• Prophylactically in cardiac catheterization, after open heart surgery and in cases of brady-

There are no absolute contraindications; however, it is advisable to avoid pacing in the fol-

Equipment used in transcutaneous cardiac pacing includes the following (**Figure 15**):

cardia-dependent tachycardias (e.g., torsades de pointes)

• Bradyarrhythmias secondary to profound hypothermia

*8.1.3. Contraindications*

88 Essentials of Accident and Emergency Medicine

• First-degree AV block

• Mobitz type I block • Stable escape rhythm

*8.1.4. Equipment needed*

• Pacing unit

• Cardiac monitor

• Pacing electrodes (pads)

• Airway equipment

• Defibrillator (see the image below)

**Figure 15.** Defibrillator with pacing capability.

• Procedural sedation/analgesia medications

lowing conditions:

The electric pads can be placed either in anterolateral position or anteroposterior position.

The anterior electrode should have negative polarity and should be placed at the cardiac apex or at lead V3 position.

The positive or posterior electrode 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) (**Figure 16**).

To initiate TCP, after application of pads and activating the device, turn the selection knob to the "pacer" mode, and select pacer rate of 60–80; as shown in **Figure1**.

Select the current, and look for one QRS complex after each pacing spike. This is called "electrical capture." Look for corresponding pulse by checking patient's pulse (**Figure 17**). If the pulse corresponds with the electrical capture along with improved BP and clinical status of the patient, "mechanical capture" is attained as shown in **Figure 3**.

The electrical output should be started from maximum output if the patient is in cardiac arrest, and then decrease to keep 10–15 mA above the threshold to maintain adequate mechanical capture.

**Figure 16.** Pacing electrode pads of external pacing unit and locations in which each pad should be placed.

**References**

emergency-critical-care;2015

BA92AD27281939DB1EB8

1st-ed-560000

dp/0781788846

3578856]

traindications

Emergency-Medicine-6th-Ed-PDF-Tahir99-VRG

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Williams & Wilkins; 2004:183-188

Philadelphia: Lippincott; 1990. 306

and Critical Care Society Symposium, May 1997 (poster)

ed. Chicago: American College of Surgeons; 1997. p. 150

[14] http://www.trauma.org/thoracic/CHESTtension.htmlPreparepatient

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4613415/complications

[1] http://www.lww.co.uk/emergency-medicine-toxicology/decision-making-in-

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[2] https://www.cambridge.org/core/books/emergency-airway-management/65F6E8117405

[3] https://www.scribd.com/document/353543024/Roberts-Hedges-Clinical-Procedures-in-

[5] http://bookstore.acep.org/emergency-department-resuscitation-of-the-critically-ill-

[6] https://www.amazon.com/Emergency-Medicine-National-Medical-Independent/

[7] https://www.elsevier.com/books/rosens-emergency-medicine-concepts-and-clinical-

[8] Gambee MA, Hertzka RE, Fisher DM. Preoxygenation techniques: Comparison of three minutes and four breaths. Anesthesia and Analgesia. 1987;**66**:468-470. [PubMed:

[9] Smith CE. Rapid sequence intubation in trauma. The 10th Annual Trauma Anesthesia

[10] Schneider RE, Caro DA. Pretreatment agents (Chapter 16). In: Walls RM, Murphy MF, editors. Manual of Emergency Airway Management, 2nd ed. Philadelphia: Lippincott,

[11] American College of Surgeons. Advanced Trauma Life Support Instructor Manual. 6th

[12] Taylor RW, Civetta JM, Kirby RR: Techniques and Procedures in Critical Care.

[13] Britten S, Palmer SH, Snow TM. Needle thoracentesis in tension pneumothorax: Insufficient cannula length and potential failure. Injury. 1996;**27**(5):321-322. [PubMed: 8763284]

[16] http://www.emedicine.com/med/topic2793.htm#section~relevant\_anatomy\_and\_con-

[18] Intraosseous [Guideline]. Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, et al. Part 14: Pediatric advanced life support: 2010 American

[17] Chest tube Life in the fast lane/Wikem.org/BTS guidelines/American chest society

[4] http://accessemergencymedicine.mhmedical.com/book.aspx?bookID=683

**Figure 17.** Rhythm strip showing failure to capture in the first four pacing stimuli that did not produce any pulse. When capture occurred, each pacing artifact is followed by QRS complex (albeit bizarrely shaped) and pulse.

However, in a patient who has a hemodynamically compromising bradycardia but is not in cardiac arrest, the operator should start from a low current output to get an electrical capture and slowly increase the output from the minimal setting until mechanical capture is achieved.

#### **8.3. Complications**

