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Presented By:

Barbara Furry, RN-BC, MS, CCRN, FAHA

Director The Center of Excellence in Education
Director of HERO

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What is a definitive treatment to offer a
patient in third degree heart block with a
QRS width of 0.12 seconds?
1. Atropine 0.5mg IV
2. Transcutaneous pacemaker
3. Epinephrine 1mg IV
4. Dobutamine 2-10mcg/kg per min
• Transcutaneous pacing (TCP) electrical stimulation from
electrode pads to induce cardiac depolarization

• Rapid, safe and non invasive

• Increase HR and improves cardiac output

• Short periods

• Therapeutic bridge
• Electrical concepts
– Electrical circuit
• Pacemaker to patient, patient to pacemaker

– Current- the flow of electrons in a completed circuit

• Measured in milliamperes (mA)

– Voltage – a unit of electrical pressure or force causing

electrons to move through a circuit
• Measured in millivolts (mV)

– Impedance- the resistance to the flow of current

• Symptomatic sinus bradycardia, sinus arrest, or
brady-tachy syndrome
• Mobitz II second- and third-degree heart block
• Symptomatic AF with slow ventricular response
• Escape rhythms not responding to drug therapy
• BBB in the setting of AMI
– New-onset left bundle branch block
– Right bundle branch block with left axis deviation
– Bifascicular block
– Alternating bundle branch block
• Noninvasive pacing can be used when invasive pacing is
undesirable - patients with the potential for excessive
bleeding - receiving fibrinolytics

• Where there is increased potential for infection

• Or placement of a temporary wire might be difficult - in

patients with tricuspid valve prosthesis.
Noninvasive pacing should be used on standby when the
patient is clinically stable yet may quickly decompensate
or become unstable:
• Cardiac patients undergoing surgery/cath lab
• Acute MI and signs of early heart block
• Patients needing surgery for permanent pacemaker
• Pulse generator change, or lead wire replacement
• Patients at risk of developing post-cardioversion
• Awake, hemodynamically stable patients

• Severe hypothermia

• Non-intact skin at the site of pacemaker pad

• ECG monitor/defibrillator/pacer

• ECG electrodes and pacing pads

• Resuscitation supplies

• Drugs for sedation & analgesia

• Explain the procedure

• Pacer pads
• Skin cleaned, dried and clipped

– Anterior –Posterior “sandwiches”

• Anterior pad: just to the left of the sternum or
below the left breast
• Posterior pad: to the left of the spine, just below
the inferior pole of the left scapula
• Anterolateral
– Right anterior pad: right of the sternal
margin, at the second or third intercostal
– Left lateral pad: left fourth or fifth intercostal
space, at the midaxillary line
• Set The Machine
– Mode:
• Fixed (asynchronous)
• Demand (synchronous) avoids electrical impulse
output during the repolarization phase which could
cause VT/VF

– Rate
• Set the rate 20 above patient intrinsic rate
• If no intrinsic rate, set to 100
– Energy
• Pacemaker initial output of 0 mA
• Increase the output until each pacer spike is
followed by a wide QRS complex (electrical
• Decrease the output mA to maintain capture at the
lowest possible energy
• In cardiac arrest start at max energy and decrease
the output after capture is achieved
• Refers to the successful stimulation of the myocardium
that results in depolarization

• Evidenced on EKG by a pacemaker spike followed by a

wide ventricular complex
• Patients can achieve capture at 50 to 90 mA but
individual thresholds vary
• Capture thresholds are not related to body surface area
or weight
Related to:
• Recent thoracic surgery
• Pericardial effusion/tamponade
• Hypoxia
• Acidosis
• Pacemaker has delivered a pacing stimulus that was
unable to initiate depolarization of the myocardium and
subsequent myocardial contraction

• Evidenced on EKG by pacemaker spikes that are not

followed by a QRS complex for ventricular pacing
Loss of Capture
• Assess the patient
– Quality of pulse
– Observe for signs of improved cardiac output, mental
status, BP and pulse ox
• Evaluate pads every 30 minutes to avoid skin burns and
change place after few hours
• Assure adequate sedation and analgesia if
hemodynamics allows

• Treat arrhythmia & plan for definitive pacing if medical

intervention is not successful
• Failure to detect VF
• Pain
• Skin burn
• Failure to capture
• Failure to pace
• Hiccups
• Sensing is the ability of the demand pacemaker to
identify electrical activity which stems from the
• Undersensing occurs when the pacemaker does not
sense intrinsic activity, and delivers a pace pulse
• To correct undersensing select a different lead or
reposition the ECG electrodes
• These troubleshooting measures focus on changing the
appearance of the ECG signal to the monitor in order for
proper sensing to occur
• Skin preparation may need to be repeated and new
ECG electrodes applied
• Oversensing is inappropriate inhibition of a demand
pacemaker due to detection of signals other than R
waves, such as muscle artifact or T waves

• When oversensing occurs the pacemaker will not

maintain the set rate. The actual pace rate will lag
behind the set pace rate

• If oversensing persists, change to a different ECG lead

or reposition the ECG electrodes
• The typical patient who benefits from noninvasive pacing
is one with a primary conduction disturbance or transient
disorder such as a post-cardioversion bradycardia or
bradycardia secondary to drug toxicity.

• Early intervention is key!

• Pacing is less likely to benefit patients who have been in

prolonged cardiac arrest or have extensive myocardial
damage or cardiac trauma
In Conclusion
• Noninvasive pacing will not convert rhythms such as
ventricular fibrillation, atrial fibrillation or atrial flutter

• Noninvasive pacing is a valuable therapy in emergency

cardiac care.

• The basic principles of invasive pacing apply to

noninvasive pacing

• Noninvasive pacing allows rapid initiation of emergency

pacing and “buys time” to stabilize the patient and plan
further care