Using capnography to confirm capture with transcutaneous pacing (TCP)

Those of you who have been following me for a while (here and other online forums) know that I have searching for cases where a patient was successfully paced with a Lifepak 12.

I have reviewed dozens of cases where the treating paramedic thought the patient was being paced, but the rhythm strips showed only false capture.

Imagine my surprise when Robbie Murray (Operations Chief for Sussex County EMS) taught a capnography class for Hilton Head Island Fire & Rescue!

It was a wonderful class, and I learned a lot about capnography, but the part that really stood out was a couple of rhythm strips that showed TCP with true electrical capture!

That’s just something you don’t see every day. Trust me on this point. I’ve been paying attention!

Robbie was gracious enough to email them to me so I could share them with you.

Apparently for this intubated patient, there was a marked rise in CO2 as soon as electrical (and mechanical) capture was achieved. What a novel and interesting use of waveform capnography!

One thing I’d like to point out is that both of these rhythm strips show TCP @ 140 mA! That’s important because the most common mistake I’ve seen with TCP is failure to increase the milliamperes high enough to achieve electrical capture.

Yours truly captured @ 120 mA with the Lifepak 12.

So, chalk up another “score” for waveform capnography and thanks again to Robbie Murray for sharing these interesting rhythm strips!

See also:

Transcutaneous pacing (TCP) The problem of false capture

Transcutaneous pacing (TCP) with a Lifepak 12

58 year old male CC: Unconscious (Transcutaneous pacing failure in the setting of hyperkalemia)

Transcutaneous pacing (TCP) for asystole

4 Comments

  • Must be nice to be able to pace and monitor wave form ETCO2 simultaneously. Our Zoll M-series monitors do not have this as an option, however, the numeric reading may still be used.

  • Christopher says:

    They could show II, SpO2, and CO2 on the LP12. Could even show II, SpO2 and a trend graph of CO2 over time.

  • Bill says:

    Great stuff. It really makes sense though. We are taught that a ROSC will be reflected by an increase in ETCO2 numbers, so will mechanical capture. It is not spontaneous circulation but it is much more efficient than beating on the chest!

    Reminds of a call where we had a ROSC and nobody believed me. I assured them that a jump from 20 or so to 60 on the ETCO2 certainly indicated ROSC whether they had a palpable pulse/BP or not. Same applies here.

    Makes me wonder. Any studies around that show maximum sustainable blood pressures obtained from performing good, solid compressions?

  • TatonkaDTD says:

    Am I missing something here?  There's no significant difference between the ETCO2 in the two waveforms presented…only the scales are different…are both of these with successful capture?  If so, what was the ETCO2 prior to getting mechanical capture?

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EMS 12-Lead

Cardiac Rhythm Analysis, 12-Lead ECG Interpretation, Resuscitation
Comments
Sean V
Rate Related VS. Primary ST-T Changes:
Also forgot to mention decrease the FiO2, 3LPM is getting us a SpO2 of 98%, titrate down so we staying at or above 94%. No need to hyperoxygenate & create all those fun free radicals. I would also include using an EtCO2 nasal cannula, lets get another measure of our cardiac output.
2014-09-20 02:32:20
Sean V
Rate Related VS. Primary ST-T Changes:
Atrial Fibrillation w/ Rapid Ventricular Response. There appears to be possible Delta Waves, the most prominent being in aVL, also leads I, II, and V6. In the EMS 12-Lead there appears to be a fusion beat, 3rd in V2, slurred R-wave appears quite consistent with a Delta wave. I would consider WPW as the primary…
2014-09-20 02:28:16
Brian
Rate Related VS. Primary ST-T Changes:
Afib. There is widespread depression in most leads and aVR has some elevation...but I am skeptical about this ecg. If a quick fluid challenge of 500-1000cc did not slow down the HR I would give him some diltiazem (5mg increments is our protocol or 0.25mg/kg) and slow the rate down a bit and see if…
2014-09-19 21:02:48
Michael Schiavone
Rate Related VS. Primary ST-T Changes:
Isolated ST elevation in AVR with ST depression in several leads. Rapid, irregular rate suggests AFIB with RVR. I would provide entry note with this exact description and leave it to hospital whether or not to activate cath lab. My EMS treatment: IV access, 324 mg. ASA, NTG, Cardizem .25 mg/kg over 2 minutes, consider…
2014-09-19 20:30:35
Dayne
Rate Related VS. Primary ST-T Changes:
AF with RVR @167, LVH and prolonged QT. ST depression to I,II and V3-6 and reciprocal elevation to aVR equal to or >1mm highly suggestive of LMCA or 3-vessel disease. High specificity for proximal occlusion. Aspirin, GTN, IV access, Spo2 >95%, Transport to nearest PCI/Cath Lab facility ASAP
2014-09-19 10:52:36

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