Transcutaneous Pacing Success!!! Part 1

Anyone trained in transcutaneous pacing (TCP) needs to be able to identify the rhythm below instantly.

False-capture with transcutaneous pacing.

Successful transcutaneous pacing?

It shows a patient being transcutaneously paced at 80 bpm and 125 mA on a LifePak 12 [the strip is labelled 130 mA but that refers to a point just past the end of the paper, I promise].

Well, actually, it shows attempted pacing. Despite the generous current being delivered there is no evidence of successful electrical capture. Without electrical capture there cannot be mechanical capture, so the patient’s pulse at the moment is only 10 bpm.

Here are the patient’s two native QRS complexes — the only ones generating a cardiac output as a result of his exceedingly slow baseline rhythm.

Though they resemble QRS complexes, the fourteen other “blips” you see on the strip are actually just artifact from the pacer. This phenomenon is commonly referred to as “false capture” and it is a huge problem.

The Problem of False Capture

On November 12, 2008, Tom Bouthillet published an article on this blog that hit me as a revelation and changed the way I approach transcutaneous pacing.

Transcutaneous Pacing (TCP) – The Problem of False Capture

You need to go read it right now. I’ll wait here.

Learn something.

Before encountering that post I had no idea how difficult it could be to achieve and identify successful transcutaneous pacing. Since then I’ve seen dozens of cases of attempted TCP — both in person and shared by colleagues and readers — but very few of them have demonstrated even intermittent capture.

There’s a catch: in most of those cases, the treating providers were absolutely certain they had achieved good capture. Patients woke up; non-invasive blood pressures improves; mechanical capture was confirmed with pulse palpation — but regardless of how confident the team managing the patient was, in almost every case the rhythm strips they showed me were pathognomic of false capture.

Tom turned me into a TCP skeptic and that is in every way a good thing.

I don’t care how strong a patient’s radial pulse feels while they are being transcutaneously paced; you cannot have mechanical capture without electrical capture. And without true mechanical capture, any improvement in the patient’s condition is merely the result of noxious stimuli being provided 60-80 times a minute — often for hours on end. The patient might become more alert, but it is not because their heart rate has increased significantly.

Patients get admitted overnight on ineffective transcutaneous pacing.

While pacing isn’t always a terrible experience if the current is increased slowly and the patient understands what is going on, being shocked all night to zero benefit sounds like torture to me.

Again, for more information on the problem of false-capture and how to identify ineffective pacing go re-read Tom’s article, but what follows is a case that demonstrates false-capture, true-capture, and two objective ways of confirming mechanical capture.

The Case

The details of the case are not overly relevant, but let’s say a patient presents quite unwell with a pulse of 20 bpm. No es bueno. Here is his initial 12-lead:

A very sick heart.

Sinus rhythm w/ marked sinus arrhythmia, high-grade AV-block (fixed PR-interval), and RBBB. There is not a single measurement or computerized statement that I agree with here. Remember: the sicker your patient, the less useful the machine’s diagnosis becomes.

 

Atropine is administered and fails to improve the heart rate. Time to start transcutaneous pacing. Here’s what we see when we turn the monitor’s Pacer function on.

Complete heart block with a ventricular rate of 15 bpm.

With “demand” pacing turned on (usually the default), the machine tracks the native QRS complexes as evidenced by the inverted triangles just above each QRS but since it is set to 0 mA no current is delivered and there are no pacing spikes.  The rhythm here appears to be complete heart block with a ventricular rate of approximately 15 bpm.

 

The current is increased from 0 mA to 10 mA.

TCP at 10 mA with no capture.

There are prominent pacing spikes at 80 bpm with tiny blips after them that almost look like P-waves (they’re not). You can see the patient’s underlying rhythm marching through at approximately 20 bpm and being tracked by the monitor.

 

The current is increased from 10 mA to 30 mA.

TCP at 30 mA with no capture.

This strip looks very similar to the prior tracing except that the blips following the pacer spikes seem slightly deeper.

 

The current is increased from 30 mA to 50 mA.

TCP at 50 mA with no capture.

Similar to the last tracing, but the post-pacer blips are definitely deeper.

 

The current is increased from 50 mA to 70 mA.

TCP at 70 mA with no capture.

More of the same. Still no capture.

 

The current is increased from 70 mA to 90 mA.

TCP at 90 mA with no capture.

Sensing a pattern?

 

Most providers give up on transcutaneous pacing before even reaching 90 mA; having read Tom’s article though, you know that is a fallacy.

The current is increased from 90 mA to 110 mA.

TCP at 110 mA with no capture.

More of the same pattern and still no capture.

 

Keep going…

The current is increased from 110 mA to 125 mA.

TCP at 125 mA with no capture.

This is the same tracing shown at the top of this article. After deliberately walking our way up from 10 mA does it still look like there could be capture?

 

Don’t give up yet…

The current is increased from 125 mA to 130 mA.

TCP at 130 mA with intermittent capture.

Finally! A Change!

We finally see a few complexes that demonstrate true electrical capture! Note how the true-capture beats are followed by wide, obvious T-waves, while the false-capture pacer artifacts are only followed by diminutive pseudo-T-waves.

 

Spurred on by signs of success, the current is increased to 135 mA.

TCP at 135 mA with mostly successful capture.

Mostly capture! There are two pacer spikes without capture but the majority of the rhythm is finally composed of complexes that show true electrical capture.

 

The patient will be leaving the emergency department to go to radiology so the current is increased from 135 mA to 145 to ensure safe capture through the trip. Just before leaving the resus bay a problem is noted though…

TCP at 145 mA with an episode of failed capture.

It looks like we’re losing capture…

What started out as a couple of dropped complexes has progressed to a string of six non-captured pacer spikes… This will not do.

Time to up the current a bit more to 150 mA.

TCP at 150 mA with mostly successful capture.

This is a bit better but there are still a couple of non-capture beats. That is, until…

TCP at 150 mA with an episode of failed capture.

Gah! Lost capture again! This patient is never going to make it to radiology.

 

The current is increased to 155 mA…

TCP at 155 mA with several episodes of failed capture.

Ugh, still no consistent capture.

 

Not one to give up, you increase the current to 165 mA. Remember: Tom taught us that the monitors go up to 200 mA for a reason — if a patient needs 200 mA to capture and stay alive then that is simply what they need. The rate is also decreased to 70 bpm (just because).

100% transcutaneously paced rhythm at 165 mA and 70 bpm.

Finally! This strip shows a 100% transcutaneously paced rhythm. Note: this is lead II.

We finally see consistent 100% capture, a pattern which continues through the patient’s trip to radiology and persists over the next hour.

Note that the above strip shows lead II; below are two more strips with the same 100% paced pattern but viewed through leads I and III (just to show how pacing can look different depending on the lead used).

Successful transcutaneously paced rhythm as seen in lead I. The pause at the start of the strip is suspicious for a non-conducted pacer spike but since it’s not well visualized we won’t worry about it here.

Successful transcutaneously paced rhythm as seen in lead III.

 

Below is one more perspective of successful electrical capture; this time from a GE DASH bedside monitor.

Successful capture on a GE DASH monitor. Note that at this point the setting for the rate has been decreased to 50 bpm.

Successful capture on a GE DASH monitor. Note that at this point in the resus the pacing rate has been decreased to 50 bpm.

 

An hour later, after the patient has stabilized, a change is noted on the monitor.

This strip shows sinus rhythm at 75 bpm with a first-degree AV-block. There are no paced complexes and the monitor is properly tracking the patient’s underlying rhythm.

 

Success! You’ve supported the patient through his bradycardic ordeal (hitting a lowest-recorded HR of 10 bpm) and now he has resumed a sinus rhythm of his own volition. A 12-lead ECG is captured.

Sinus rhythm at 75 bpm,

Sinus rhythm at 77 bpm, first-degree AV-block, left bundle branch block, left axis deviation, poor R-wave progression.

 

The rest of the patient’s emergency department and intensive care unit courses are uneventful (and his labs, including potassium, unremarkable) and he is discharged back home in healthy condition… with the addition of an implanted pacemaker.

 

For the sake of brevity today’s discussion only focused on identifying electrical capture. Check out Part 2 of this case where we discuss two objective methods of confirming mechanical capture.

Can’t get enough TCP?  As a companion to the original article by Tom, Christopher Watford wrote a second in-depth review examining just why we are programmed to miss false capture so often.

Alternatively, check out everything our blog has written on the topic of transcutaneous pacing.

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