Transcutaneous Pacing for Nurses

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Picture of Alyx Presler
Alyx Presler
Emergency department nurse turned to the CVICU dark side. Revels in the airway, FOAMed, hiking, and hanging out with a black lab named Blue Gill.

The Pre-brief

Transcutaneous pacing (TCP) is a temporary, exogenous form of cardiac pacing which involves placing two electrodes on the patient’s skin. TCP causes a noninvasive electrical depolarization, thereby forcing contraction of the heart muscle. TCP maintains cardiac output by bypassing the underlying dysrhythmia. Temporary pacing is considered when a permanent pacemaker is not emergently indicated, not available, or the patient is too unstable for the procedure.

Indications for TCP:

  1. Bradycardia with hemodynamic instability, which is unresponsive to medications
  2. Third-degree/complete heart block and other heart blocks with complications and/or hemodynamic instability
  3. Overdrive pacing/tachydysrhythmia

Prior to beginning pacing, consider reversible causes of the presenting dysrhythmia. Most often pacing is utilized in bradycardias, some reversible causes are myocardial infarction, electrolyte imbalances, drug toxicity, etc. Additionally, KNOW YOUR MONITOR! Get familiar with the settings and how to manipulate the monitor to do what you need. 

Finally, don’t forget sedation/analgesia if time allows for it. Assure the patient is kept as comfortable as possible prior to and during pacing.

How To:

  • Anterior-Posterior electrode placement, anterior-lateral positioning if contraindicated to roll patient
  • Set monitor to “Pace” mode on the monitor
  • Begin with pacing rate 30 bpm above the intrinsic rate
  • Set milliamperes (mA) to 20
  • Increase by 10mA every few seconds until capture
  • Set 5-10 mA above capture

If unable to achieve capture before 120-130 mA, reposition electrodes and begin again.

What is capture?

Capture is the goal in TCP. When achieved, pacing is successful! Electrical capture is confirmed by an ECG reading – widened QRS following every pacer spike. Mechanical capture is determined by a palpable pulse and other signs of increased circulation (increased blood pressure, improvements in skin color and warmth, and improved level of consciousness). Be sure to check for mechanical capture as well as electrical capture.

Following capture, be sure to continue to reassess skin for burns and ensure adequate pain management.

The Debrief:

  • AP electrode positioning
  • KNOW YOUR MONITOR
  • Don’t forget to assess for mechanical capture
  • Adequately manage pain

References

    • Adams A, Adams C. Transcutaneous Pacing: An Emergency Nurse’s Guide. J Emerg Nurs. 2021 Mar;47(2):326-330. doi: 10.1016/j.jen.2020.11.003. PMID: 33706976.
    • Self M, Tainter CR. Overdrive Pacing. [Updated 2020 May 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549874/

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