Temporary Cardiac Pacing

• Definition: a temporizing treatment for bradyarrhythmias in which electrical impulses are delivered through pacing pads placed on the chest wall to stimulate cardiac contraction

• Indication: unstable bradycardia for which pharmacotherapy alone either is ineffective, not readily available, or contraindicated

• Contraindications: no absolute contraindications

• Pacemaker spike: A narrow upward deflection on an ECG tracing caused by an electrical impulse from a pacemaker.

• Electrical capture

  • Successful conduction of current from an external pacemaker to the conduction system of the heart

  • Manifests on ECG as a pacer spike immediately followed by a widened QRS complex.

• Mechanical capture

  • Physical cardiac contraction that occurs when current is conducted from an external pacemaker

  • Manifests as a palpable pulse, a pulse oximetry waveform, or ventricular contraction visible on POCUS.

1. Apply pacer pads to the chest.

2. Connect the cable from the pads to the pacemaker.

3. Turn on the pacemaker and select the pacer function.

4. Verify that the pacemaker detects the patient's intrinsic rhythm.

5. Set the pacing rate higher than the patient's native heart rate (generally 60–70/minute).

6. Increase the current output until electrical capture occurs. [6]

7. Confirm mechanical capture clinically or using POCUS.

8. Maintain the current 5–10 mA above the minimum current required for mechanical capture. [6][7]

9. Provide procedural sedation for conscious patients, unless there is persistent hemodynamic instability.

In the unconscious or near-arrest patient, start the current at maximum and decrease until capture is lost. Maintain the final output at 5–10 mA above this threshold

• Pain

• Skin burns

• Loss of electrical capture and/or mechanical capture

• Tachyarrhythmias (e.g., ventricular fibrillation)

• Cough and/or hiccups

• Pacemaker syndrome

• Definition: The delivery of electrical impulses to stimulate cardiac contraction using an electrode placed via a central venous access site into the right ventricle; often used as a bridge to permanent pacemaker implantation

• Indications [4]

  • Symptomatic sinus node dysfunction

  • Second-degree or third-degree heart block

  • Afib with SVR

  • CIED malfunction

  • Also used for temporary antitachycardia pacing

• Contraindications: prosthetic tricuspid valve, severe hypothermia

• Complications: Usually related to vascular access