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· Hemodynamically significant bradydysrhythmias unresponsive to atropine treatment
· (Hypotension, chest pain, pulmonary edema, altered mental status)
· temporary cardiac pacing until the more permanent transvenous pacing can be initiated or until the underlying cause of the bradydysrhythmia can be corrected (i.e. electrolyte disturbance, drug OD)
· asystolic cardiac arrest
· more likely to be successful when initiated early after a witnessed arrest (must be attempted within 10 minutes)
· Active pacing may not be necessary for hemodynamically stable awake patients. Instead, attach the pacing pads and turn the pacer on to “standby” mode due to the potential for deterioration (i.e. heart block resulting from cardiac ischemia). Then the pacer can be quickly activated in the event the patient becomes “unstable” due to the bradyarrhythmia.
· Non-intact skin at the site of the electrode placement
· ACLS equipment and medications (“code box” and “code cart”)
· Airway equipment (Oxygen, suction, BVM, intubation supplies, etc.)
· Pacemaker/monitor (and defibrillator)
· 2 sets of electrodes
· ECG electrodes for rhythm monitoring
· Pacing electrode pads
PRE-PROCEDURE PATIENT EDUCATION:
For awake patients, explain the procedure, advise them of the benefit of pacing, potential risks of further deterioration if pacing is not attempted, and of the potential complications (listed below).
· If time permits and the patient is hemodynamically stable, correct metabolic and electrolyte abnormalities, or reverse unwanted drug effects which may be the cause of the bradycardic rhythm.
· Provide supplemental O2 and obtain IV access.
· Ensure airway management equipment is readily available (suction, BVM, O2, laryngoscope, ETT, pulse ox, etc.)
· Bring “code box” to bedside due to potential urgent need for ACLS meds.
· Strongly consider sedation
· Turn monitor on to “pacing” mode
· Lead placement: Attach monitor leads (“white on right”, “smoke over fire”) to patient to confirm rhythm
· “White-on-the-right” will help you to remember the white electrode is placed on the right side of the chest just below the right clavicle
· “smoke over fire” will help you to remember that the black lead is placed on the left chest just below the left clavicle, and the red lead is placed in the left midaxillary line below the expected PMI of the heart
· pacing pad placement:
· anterior pad just to the left of the sternum, and posterior pad on the patient’s back to the left of the spine. (This technique “sandwiches” the heart between the pads)
· attach pads to the instrument cable and attach cable to pacer, carefully check all connections
· select a pacing rate (target heart rate)
· usually range of 60-70 beats per minute, target rate is chosen to maintain cardiac output, improve BP and improve pre-pacing symptoms
· select power/output
· for hemodynamically compromising bradycardia without cardiac arrest, start at 0 mA and slowly increase the output until capture is achieved
· in cardiac arrest setting, start at max power setting and decrease the output after capture is achieved
· assessment of capture: look at the ECG tracing on the monitor for pacer spikes that are each followed by a QRS complex
· SEE DIAGRAMS of CAPTURE AND NON-CAPTURE TRACINGS
· Assess patient hemodynamic stability (measure blood pressure, assess tissue perfusion) and tolerance to pacing. Provide sedation/analgesia PRN.
DOCUMENTATION FOR THE MEDICAL RECORD:
· A brief progress note should be written in the chart to include the indications for pacing, pre-paced rhythm and 12-lead ECG findings, medications given, energy level/settings required, any complications that occurred, patient assessment and outcome, disposition, and the notification of attending physician and family members.
COMPLICATIONS, Prevention & Management:
· Failure to recognize VF (which is treatable with defibrillation) due to the size of pacing artifact on the ECG screen. You should frequently re-assess the patient and the rhythm, defibrillation is indicated immediately if VF occurs.
· Induction of other dysrhythmias. Follow ACLS guidelines for arrhythmia management.
· Soft tissue discomfort may result from pacing. Ensure adequate analgesia and sedation.
· There is a potential for local cutaneous injury with prolonged TCP. Remember TCP is temporary, correct possible underlying causes for bradydysrhythmia, and/or arrange for transvenous pacemaker placement.
DOCUMENTATION FOR THE MEDICAL RECORD:
· Write a brief progress note in the chart describing the indications for TCP, pre-paced rhythm and 12-lead ECG findings, post-TCP patient assessment and outcome, pacer settings, medications used, disposition, and notification of family and attending physician.
· If the TCP was initiated during a “code,” most facilities have a “code sheet” to be filled out by a member of the code team. This sheet should be reviewed for accuracy and completeness and signed by the physician (resident and/or attending) in charge of the code.
ITEMS FOR EVALUATION:
· Recognizes indications for TCP
· Understands mechanics of pacer/monitor and is familiar with any necessary equipment
· Recognizes capture and non-capture
· Explains procedure/educates patient
· Addresses patient comfort and sedation
· Completes appropriate documentation for medical record
· Effectively communicates with patient, family and involved physicians