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Transcutaneous pacing (TCP) is a temporary, non-invasive cardiac pacing technique used to manage bradyarrhythmia. It involves the delivery of electrical impulses through external pacing pads placed on the chest.
It should be noted that TCP is not a reliable method for sustained ventricular stimulation and should only be used as a temporary measure until a more definitive solution, such as transvenous pacing, is available. Its key advantages include ease of use, quick establishment, and the ability to be initiated at the bedside before expert intervention is possible.
This guide outlines a step-by-step approach to transcutaneous pacing in an OSCE setting and is NOT intended for direct patient care guidance.
Indications
Transcutaneous pacing is indicated for:
- Bradyarrhythmia with life-threatening features unresponsive to atropine or when atropine is contraindicated
- Bradyarrhythmia with a high risk of asystole
Life-threatening features and risk of asystole
There are four life-threatening features of bradyarrhythmia:
- Shock
- Syncope
- Myocardial ischaemia
- Heart failure
Several clinical characteristics indicate a high risk of asystole, indicating urgent pacing:
- Recent asystole
- Mobitz II AV block
- Complete heart block with broad QRS
- Ventricular pause >3 seconds
Transcutaneous pacing device
While all transcutaneous pacing devices operate similarly, there might be differences due to the machine’s model. Familiarise yourself with the machine available in your healthcare setting. The key elements include:
- Power switch: turns the device on and off
- Screen: shows ECG, pacing rate, output current (mA), etc.
- Mode selector button: allows selection between different pacing modes (demand or fixed rate)
- Pacing rate control: adjusts the pacing rate
- Output current control: adjusts the current strength for successful electrical capture
- ECG monitoring leads: captures and displays the patient’s ECG
- Adhesive pacing pads: electrodes placed on the chest to deliver pacing impulses
- Start/stop button: initiates or stops pacing
Note: some defibrillators can also deliver transcutaneous pacing, which can be done by putting the defibrillator in pacing mode.
Gather equipment
Gather the appropriate equipment for transcutaneous pacing:
- Resuscitation trolley
- Transcutaneous pacing device or defibrillator
- Self-adhesive defibrillation pads
- ECG monitoring electrodes and leads (if required)
- Skin cleaning wipes (alcohol/chlorhexidine)
- Razor (if hair needs to be removed for better pad attachment)
Sedation
Intravenous analgesia or sedation is typically required, especially if prolonged pacing is needed, as the procedure is painful.
A competent healthcare professional (typically an anaesthetist) must carry out the sedation and provide airway support.
Introduction
Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.
Don PPE if appropriate.
Introduce yourself to the patient, including your name and role.
Confirm the patient’s name and date of birth.
Briefly explain what the procedure will involve using patient-friendly language.
Example explanation
“This procedure is called transcutaneous pacing. It helps manage your heart rate by delivering small electrical pulses through pads on your chest.
For the procedure, you will need to lie flat on your back while we place sticky pads on your chest. These pads will send small electrical impulses to stimulate your heart. You may feel a mild tingling or twitching sensation in your chest muscles due to the current. It may be uncomfortable, but we can give you painkillers or sedation to help.
The main risks are mild skin irritation and temporary discomfort. In rare cases, there may be brief changes in heart rhythm, but we will be closely monitoring you at all times.”
Gain consent to proceed with transcutaneous pacing. Written consent should be obtained as best practice, although this may not be possible in emergency situations.
Check if the patient has any allergies (e.g. latex).
Pre-procedure
Contraindications
Contraindications to transcutaneous pacing include:
- Patient refusal (absolute contraindication)
Patient positioning
The patient should be in a supine position.
Required monitoring
It is important to monitor the patient’s vital signs throughout the procedure, particularly continuous cardiac monitoring.
As the procedures involve sedation, airway monitoring and assessment are required throughout. Airway manoeuvres or adjuncts are typically required, but this should be led by the anaesthetist.
Transcutaneous pacing
Preparation
1. Bring the transcutaneous pacing device
2. Make sure the patient is supine and expose the patient’s chest, if not already done
3. Clean, dry, or shave the skin if time permits to ensure better pad attachment
4. Attach the pads in the appropriate position
5. Attach the ECG monitoring electrodes and leads (if required) and confirm the rhythm is displayed on screen
Pad positions
The anterolateral position is preferred unless this is not possible (e.g. chest trauma or an implanted device in this position).
If using a pacing device not capable of defibrillation, use the anteroposterior position so that defibrillator pads can still be applied in the right pectoral and apical position if needed.
Anterolateral (conventional pad position)
- Right pectoral pad: placed over the right pectoral muscle, just below the clavicle
- Apical pad: placed in the left mid-axillary line, overlying the V6 ECG electrode position (to the chest wall, not breast tissue)
Anteroposterior
- Anterior pad: placed on the left anterior chest wall, beside the sternum, overlying the V2 and V3 ECG electrode position
- Posterior pad: placed between the lower part of the left scapula and the spine, at the same horizontal level as the anterior pad
Pacing
For successful transcutaneous pacing, the mode, rate, and energy output must be adjusted as required.
Mode
There are two pacing modes: demand and fixed mode. Most devices operate in demand mode. In this mode, the pacemaker is inhibited if it detects a spontaneous QRS complex.
However, movement artefacts can mimic QRS complexes and inhibit pacing. To prevent this, try to minimise movement artefacts, and if this doesn’t help, switch to fixed-rate mode.
Rate
Choose an appropriate pacing rate, usually 60–90 bpm for adults. In some cases, such as complete AV block with an idioventricular rhythm at 50 bpm, a lower rate of 40 or even 30 bpm may be preferred to ensure pacing is delivered only during sudden ventricular standstill or severe bradycardia.
Energy output
1. If the device has adjustable energy output, set it at the lowest value and turn it on
2. Gradually increase the output and keep observing the patient and ECG. As the current rises, the chest muscle will contract with each impulse, and pacing spikes will appear on the ECG
3. Gradually increase the current until each pacing spike is immediately followed by a QRS complex, which indicates electrical capture (typically with an output of 50–100 mA). This confirms that the pacing stimuli are causing depolarisation of the ventricles
4. Ensure that the QRS complexes are followed by T waves. Occasionally, the pacing current may generate artefacts that look like a QRS, but a T wave will not follow these
5. The minimum output required for capture is the patient’s threshold. Set the energy output 10–20% above the capture threshold. This ensures that successful pacing occurs using the lowest energy necessary, which helps minimise unnecessary pain for the patient. If there’s an intermittent loss of capture at this output, a higher energy output can be used. Seek senior input.
Note: if the highest current is reached but capture has not occurred, try changing pad positions. If capture is still not achieved, it may indicate a non-viable myocardium or severe hyperkalaemia.
Next steps
After achieving successful capture, verify that a palpable pulse follows each paced QRS to confirm mechanical response (myocardial contraction). If electrical capture is achieved but a pulse is absent, it suggests pulseless electrical activity (PEA), which may be due to severe myocardial failure or other causes.
Once the emergency is resolved and the patient has a pulse, administer sedatives/analgesia to make the patient comfortable.
Since transcutaneous pacing is only a temporary measure, seek expert help immediately to arrange for emergency transvenous pacing.
To complete the procedure…
Ensure continuous monitoring, including cardiac monitoring.
Aim to identify the cause of the bradycardia.
Allow the patient to reposition to a position that is comfortable for them.
Dispose of sharps, PPE, and other clinical waste into an appropriate clinical waste bin.
Wash your hands.
Document the procedure, including the mode, rate, and energy of the pacing stimulus.
Reviewer
Dr Ayyaz Sultan
Consultant Cardiologist
Editor
Dr Jamie Scriven
References
- Resuscitation Council UK. Chapter 10: Cardiac Pacing. In: Advanced Life Support (8th Edition). 2021. Available from: [LINK].
- Resuscitation Council UK. Chapter 11: Peri-arrest Arrhythmias. In: Advanced Life Support (8th Edition). 2021. Available from: [LINK].
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