Cardiac Pacing Summary

Pacing Methods

  • Non-Invasive: Percussion, Transcutaneous
  • Invasive: Transvenous, Permanent

Percussion Pacing

  • For profound bradycardia with P wave activity
  • Fist thumps to precordium (20cm above chest)
  • Monitor ECG for QRS generation
  • Start CPR if no pulse promptly

Transcutaneous Pacing

  • Rapid, minimal training required
  • Painful - may need sedation
  • Pad positions: Conventional or A-P
  • Set to demand mode, rate 60-90 bpm

Transvenous Pacing

  • RV placement with fluoroscopic guidance
  • More comfortable for conscious patients
  • Lower dislodgement risk
  • Not for cardiac arrest - use non-invasive first

Capture Verification

  • Electrical: Pacing spike → QRS + T wave
  • Mechanical: Palpable pulse with each beat
  • No mechanical capture = treat as PEA

Key Points

  • Percussion pacing preferred over CPR for ventricular standstill with P waves
  • Transcutaneous: Start low energy, increase until capture
  • Transvenous: Requires expert placement
  • Always confirm both electrical and mechanical capture

Temporary Cardiac Pacing

Life-saving interventions for cardiac arrest or peri-arrest bradyarrhythmias

Methods of Pacing

Non-Invasive

  • Percussion pacing
  • Transcutaneous pacing

Invasive

  • Temporary transvenous pacing
  • Permanent pacemaker implantation

Percussion Pacing

Indications

  • Profound bradycardia causing clinical cardiac arrest
  • Preference to CPR when ventricular standstill with P wave activity

Note: If percussion doesn't produce a regular pulse promptly, start CPR immediately regardless of QRS generation

Method

  1. Use side of closed fist to deliver firm thumps to precordium (lateral to lower left sternal edge)
  2. Raise hand ~20cm above chest before each thump
  3. Monitor ECG for QRS complex generation
  4. Have second provider check for pulse with each QRS
  5. Adjust technique as needed:
    • Increase thump force if no QRS
    • Move contact point around precordium to find effective site

Transcutaneous Pacing

Advantages vs Disadvantages

Advantages Disadvantages
Rapid establishment Painful for conscious patients
Minimal training required Chest wall muscle stimulation
Non-invasive May require sedation/analgesia

Procedure

  1. Prepare patient:
    • Warn conscious patients about discomfort
    • Have IV analgesia/sedation ready
    • Remove excess chest hair if needed
    • Ensure skin is dry
  2. Pad placement:

    Preferred Positions

    • Conventional: Right pectoral (below clavicle) + left mid-axillary (V6 position)
    • Alternative (A-P): Anterior (V2/V3 position) + Posterior (between scapula and spine)
  3. Pacing setup:
    • Set to demand mode (inhibited by spontaneous QRS)
    • Select rate (typically 60-90 bpm)
  4. Initiate pacing:
    • Start at lowest energy setting
    • Gradually increase output while monitoring:
      • Chest wall muscle contraction
      • Pacing spike on ECG
    • Increase until pacing spike followed by QRS (electrical capture)
  5. Confirm effectiveness:
    • Check for T wave after QRS
    • Palpate pulse with each QRS (mechanical capture)
    • If no capture at max setting: reposition pads
  6. Next steps:
    • If effective: Seek expert help for transvenous pacing
    • If electrical capture without pulse: Treat as PEA

Temporary Transvenous Pacing

Important Consideration

Rarely appropriate to attempt during cardiac arrest - use non-invasive pacing first to achieve cardiac output, then seek expert help for transvenous placement

Clinical Pearls

  • Requires fluoroscopic guidance in most cases
  • Pacing wire typically placed in right ventricle
  • Lower risk of dislodgement than non-invasive methods
  • More comfortable for conscious patients
  • Still considered temporary - requires eventual permanent pacemaker if indicated

Key Monitoring Points

Parameter What to Assess
Electrical Capture Pacing spike followed by QRS complex + T wave
Mechanical Capture Palpable pulse with each paced beat
Patient Comfort Need for analgesia/sedation (transcutaneous)
Underlying Rhythm Watch for return of native conduction