- EXTERNAL CARDIAC PACING -

Question 1

Identify the indications related to the application of emergency external pacing

Answer 1

Symptomatic bradyarrhythmias not responding to chronotropic agents
o Heart rate <40 bpm
o Systolic BP <90mmHg
- Ventricular standstill
- Mobitz Type 11 and third degree AV block
- Brady-asystolic cardiac arrest
- Overdrive pacing of tachyarrhythmias

Question 2

Identify the nursing considerations related to the preparation of the patient for pacing

Answer 2

• Indications for pacing
• staffing and environment
• Is it appropriate to do in the emergency department at this time and do we have
• pt preparation and education
• sedation and monitoring (BP, HR, RR, airway, cardiac
  monitor)
• airway preparation
• Patient is not to be left unattended
• Nurse patient lying flat
• Observe monitor for electrical capture
• Palpate for a carotid or femoral pulse
• Check the colour and warmth of skin
• Check for improving blood pressure and level of consciousness
• Perform ECG and rhythm strips and document observations hourly
• Consider using analgesia or sedation for comfort
• During synchronous pacing ensure monitoring leads are well connected. If the monitoring
  leads disconnect pacing will cease. To resume pacing reconnect the patient and press
  ‘start/stop’.
• Asynchronous pacing does not require monitoring lead to be attached.
• If a pacing pad comes off during pacing, pacing will cease. To resume pacing, reattach the
  pad and press ‘start/stop’
• Do not use pads for any longer than eight hours of continuous pacing
• Pads to be changed every 24 hours
• To avoid an electrical shock do not touch gel area of pads during pacing.
• Ensure the Biphasic defibrillator/pacer is connected to an AC power outlet as there is
  limited battery life

Question 3

Demonstrate an understanding of demmand asynchronous pacing modes

Answer 3

(Synchronous) Demand Mode – PREFERRED AND USED WHENEVER POSSIBLE
- If no spontaneous depolarisation is sensed, the pacemaker delivers a pulse.

(Asynchronous) Fixed Mode
- The pacer will deliver pulses at the selected rate regardless of the patient’s intrinsic rate or
rhythm. USED ONLY WHEN MOTION ARTIFACT OR OTHER ECG NOISE MAKES R WAVE
DETECTION UNRELIABLE.

Question 4

Explain the steps in trouble shooting pain or discomfort during pacing

Answer 4

• Explain and set expectations with the patient on
  the procedure. Comfort and provide
  encouragement to the patient.
• Make sure electrodes have been applied following
  manufacturer’s guidelines. Electrodes should not
  be placed over bone (i.e. on the sternum or
  scapula).
• Consider analgesia or sedation.

Question 5

Identify the voltages related to both adult and paediatric pacing

Answer 5

• Adults usually start at 30 mA and work up, and rate 70 bpm (depending on situation)
• Paeds usually start at 20mA, or the lowest setting available and HR depends on age e.g. neonate 120-150

Question 6

Identify the possible complications related to external pacing

Answer 6

• Muscle stimulation
• Skin burns
• Pain
• Dysrhythmias e.g. VT if the pacemaker is left in asynchronous mode
• Failure to capture due to:
  o Electrode placement
  o Cardiac tamponade
  o Recent thoracic surgery
  o Barrel-shaped chest
• electromechanical dysfunction (electrical capture without mechanical capture

Question 7

Demonstrate the placement of electrodes and multifunction pads for pacing

Answer 7

Anteroapical – one pad/paddle is placed to the right of the sternum just below the clavicle, and the other is centred lateral to the normal cardiac apex in the anterior or midaxillary line (V5–6)

Anteroposterior – the anterior pad/paddle is placed over the praecordium or apex, and the posterior pad/paddle is placed on the back in the left or right infrascapular region.

Question 8

Explain the steps in trouble shooting failure to gain electrical capture

Answer 8

• Pacer output (mA) may be too low. Increase pacer
  output.
• Confirm electrical capture on defib (pacing spike followed by a broad and bizzare QRS)
• Check electrode placement.
• Check contact between the electrode and the
  patient.

Question 9

Define transcutaneous pacing

Answer 9

Transcutaneous pacing is used for patients who require short term or emergency pacing to initiate cardiac depolarization and myocardial contraction. This is achieved externally through a set of electrode pads

Question 10

Give other examples of different types of pacing and their uses

Answer 10

• Transvenous (pacing with a swanganz catheter)
• Epicardial (wires sutured to RA and RV, atrial wire exiting on right of sternum and ventricular wires exiting on the left side of the sternum) usually used in bypass surgery

Question 11

What drugs might you use before attempting pacing

Answer 11

Positive chronotropic agents such as atropine, isuprel, adrenaline

Question 12

List the contraindications for external emergency cardiac pacing

Answer 12

• Specific advance directives (e.g., do not attempt resuscitation for cases of pulseless electrical activity)
• Asymptomatic bradycardia
• Severe hypothermia (risk of ventricular fibrillation)