June - 2021

Jun 24, 2021
4 min

Revisiting Transcutaneous Cardiac Pacing

Transcutaneous cardiac pacing is an effective procedure for patients experiencing unstable bradycardia. Or is it? If you’ve read Tom’s introduction to the subject of false capture you’re already ahead of the game. We’ve shown case after case of unstable bradycardia patients receiving ineffective transcutaneous pacing due to a lack of capture. In each case, phantom pacing impulses are interpreted by the paramedic as electrical capture. Typically, this is confirmed by an improv

Jun 24, 2021
2 min

Transcutaneous Pacing (TCP) with a LifePak 12

I discovered an interesting quirk about the Lifepak 12 the other day. I’m sure many of you have been told (as I had been told) that the Lifepak 12 cannot perform TCP unless the limb lead electrodes are attached. There is a caveat to this (reference page 4-18 in the Operations Manual – this is a PDF file so “right-click” the link and select “save as”). If you are performing TCP in demand mode (even if you have it set well below the patient’s intrinsic rate and no pacing is bei

Jun 24, 2021
1 min

A Rare Case of Transcutaneous Pacing (TCP) with True Electrical and Mechanical Capture

EMS is called to an assisted living facility for a 79-year-old female who is found collapsed outside her apartment door. On arrival, the staff is providing adequate chest compressions. The cardiac monitor is attached. The arrest rhythm is asystole. Chest compressions are continued, an IV is initiated, and 1 mg of epinephrine is given. Now there is a regular bradycardic rhythm without P-waves at a rate of 30. The patient has a faint pulse but a blood pressure cannot be auscult

Jun 24, 2021
2 min

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 been 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 wa

Jun 24, 2021
5 min

Transcutaneous Pacing (TCP): The Problem of False Capture

Transcutaneous pacing (TCP) is perhaps the most underutilized and misunderstood intervention in all of ACLS. Why? Simple. Because it’s impossible to simulate during training. From the 2010 AHA ECC Guidelines – Part 8:3: Management of Symptomatic Bradycardia and Tachycardia “It is reasonable for healthcare providers to initiate TCP in unstable patients who do not respond to atropine (Class IIa, LOE B). Immediate pacing might be considered in unstable patients with high-degree

Jun 24, 2021
7 min

Transcutaneous Pacing Success!!! (Part 2)

This is the second half of a two-part case presentation examining transcutaneous pacing. If you didn’t see yesterday’s post I highly suggest checking out Part 1 before continuing, but if you hate learning I suppose you can start here. Yesterday we examined a series of tracings that depicted transcutaneous pacing (TCP) in all its stages: initiation, false-capture, intermittent capture, successful capture, and finally, spontaneous resolution of the bradycardia that necessitated

Jun 21, 2021
4 min

Transcutaneous Pacing Success!!! (Part 1)

Anyone trained in transcutaneous pacing (TCP) needs to be able to identify the rhythm below instantly. It shows a patient being transcutaneously paced at 80 bpm and 125 mA on a LifePak 12 [the strip is labeled 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 mecha

Jun 21, 2021
3 min

Transcutaneous Pacing: "Put It Up To Eleven!"

What. The. HECK?! But there is a short answer -- and it's actually just a number. And as the title suggests, the answer to this case is (both literally and figuratively) 11. But what are the questions? The Case EMS brought in a middle-aged male with altered mental status and an ill appearance. Over the past 3-4 days he had become increasingly weak and now seemed “out of it” to his family. He had a recent admission to the hospital for atrial fibrillation and was discharged on

Jun 19, 2021
4 min

Mastering Axis Determination: Part 6

By now you can predict the QRS axis in the frontal plane within 15 degrees as long as you have an equiphasic (or isoelectric) lead in the frontal plane. So what constitutes a normal QRS axis? What is a left axis deviation? A right axis deviation? If you don’t have a copy of the hexaxial reference system, go back to Part IV and print yourself out a copy. As a review, lead I cuts the hexaxial reference system in half horizontally, and lead aVF cuts the hexaxial reference system

Jun 19, 2021
3 min

Mastering Axis Determination: Part 5

In Part 4 I promised that I’d show you a fascinating relationship between the standard 12-lead ECG and the hexaxial reference system. You will recall that to use the hexaxial reference system, you find the most equiphasic (or isoelectric) lead in the frontal plane (first 6 leads of the 12-lead ECG) and look for the perpendicular lead on the hexaxial reference system. The example ECG we used was that of a 16-year-old female with a congenital heart defect. The most equiphasic l

Jun 19, 2021
4 min

Mastering Axis Determination: Part 4

By now you should have a fairly good grasp of how the hexaxial reference system is derived from the first 6 leads of the 12 lead ECG. Before we break down the finished diagram, let’s look at the hexaxial reference system laying on top of the patient’s anterior chest, with the arrows and leads in the position of the positive electrodes. The first thing I would like you to notice is that lead I cuts the body in half horizontally and lead aVF cuts the body in half vertically. Th

Jun 19, 2021
2 min

Mastering Axis Determination: Part 3

In Part 2 we discussed the heart’s mean electrical vector and how Einthoven’s Triangle (leads I, II, and III) can be redrawn to form the first 3 spokes of the hexaxial reference system. Essentially, we ended up with a shape like the one below: When leads I, II, and III are drawn this way (as they often are) the arrows and Roman numerals are placed in the position of the positive electrodes. (Maybe this is why Einthoven reversed the polarity of lead II!) Don’t worry, by the en

Jun 19, 2021
4 min

Mastering Axis Determination: Part 2

In Part 1, we looked at Einthoven’s Equilateral Triangle and Einthoven’s Law, and I told you that it was the key to understanding the formation of the hexaxial reference system. But before we delve further into the hexaxial reference system (the instrument we’ll be using to calculate the heart’s QRS axis) we need to address something even more fundamental. What is the heart’s electrical axis? To answer this question, I’m going to borrow an image from Prehospital 12 Lead ECG –

Jun 19, 2021
5 min

Mastering Axis Determination: Part 1

Few subjects related to 12 lead ECG interpretation provoke more controversy (or anxiety) than axis determination. It is controversial in that not everyone agrees it is a necessary skill for prehospital providers to learn. It is anxiety-provoking in that it can be difficult to understand, especially when taught poorly. I am of the opinion that axis determination is a critical skill to master. I would even go so far as to say that you cannot be competent at 12-lead ECG interpre

Jun 19, 2021
3 min

Axis Determination: Why Learn It?!

Jeff Beeson, DO, LP once said, “The eyes cannot see that which the mind does not know.” Without a proper understanding of axis, you cannot really see a 12-lead ECG. Once you fully understand axis it gives you a vocabulary that allows you to take ECG interpretation to the next level. It doesn’t help that this topic is poorly taught at all levels. Here are some examples where understanding the heart’s axis helped me make wise decisions on actual emergency calls. The most common

Jun 19, 2021
1 min

6-Step Method for 12-Lead ECG Interpretation

New video on the 6-step method for 12-lead ECG interpretation! Rate and rhythm Axis determination Intervals (PR, QRS, QT) Morphology (BBB, IVCD) STEMI mimics Ischemia, Injury, Infarct

EMS 12-Lead

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