Sno

Non-invasive Transcutaneous pacing

procedure
1. Setup
. Equipment
Cardiac monitor, noninvasive
pacemaker,defibrillator
ECG electrodes and cable
Pacing electrodes and cable
Advanced cardiac life support supplies
2. Patient/family preparation
Explain procedure to patient and family
3. Procedure:
Connect monitor and acquire baseline rhythm
strip

4. Obtain vital signs

5. Clip excessive hair on chest under pacing

electrodes

Rationale

ECG monitoring during

demand pacing must be
done using ECG
electrodes to provide a
clear ECG signal
Skin prep for ECG
electrodes improves ECG
signal quality
Annotated recordings
provide useful
documentation
Serve as a baseline for
assessing pacing
effectiveness
Nicks in skin increases
discomfort in conscious
patient

6. Apply pacing electrodes to clean, dry skin on

Anterior-posterior or
Anterior-lateral placement
7. Connect pacing cable to electrodes and to
device
8. Select demand or non-demand pacing mode

Demand mode allows

 Confirm sensing of QRS in demand mode

9. Set current at minimum if not automatically

done by pacemaker
10. Select pace rate

11. Activate pacemaker and adjust current upward

until electrical and mechanical capture are
identified

12. Acquire rhythm strips

intrinsic complexes to
take over
once the patients rate
exceeds set pace rate
Sensing needs to be
assessed prior to and
during demand pacing

Typical adult pace rates

range from 6090 PPM or
high are
enough for adequate
perfusion
Current needs to be
increased until capture is
identified.
Typical capture thresholds
range between 5090 mA,
but individual thresholds
vary markedly. Start
slowly
in conscious patients.
Increase quickly in
cardiac
arrest patients.
Electrical capture is
evidenced by wide QRS
and tall
broad T wave
Mechanical capture is
evidenced by a pulse or
signs of improved cardiac
output
recordings are essential

13.
Documentation
A. Date and time pacing initiated
B. Rhythm strips prior to and during pacing
C. Pacing mode and rate selected
D. Current required to capture
E. Patients response to pacing
F. Medication used
G. Date, time and reason pacing terminated

for documentation
When the patient is
successfully paced:
electrical and
mechanical capture
are achieved
cardiac output may
improve
the patients pulse
rate is at least equal
to the pacer rate
blood pressure may
improve
skin color may
improve

14. Troubleshooting guidelines:

1.Is there discomfort or pain during pacing?
Explain and set expectations with the
patient on the procedure. Comfort and
provide encouragement to the patient.
Make sure electrodes have been
applied .Electrodes should not be placed
over bone (i.e. on the sternum or
scapula).
Consider analgesia or sedation.

2. Is there electrical capture?

Pacer output may be too low. Increase
pacer output.
Observe the ECG monitor and not just
the patient.

Electrical capture occurs

when there is a consistent

 Check electrode placement.

Check contact between the electrode and
the patient.
Check to see if the pacer is turned on.
Check viability of the patient.

ST segment and T-wave

after each spike.

3. Is there mechanical capture?

Check pulse (palpate).

Check pulse oximeter (SpO2).
Check blood pressure.
Check skin color.
Evaluate mental status of patient.

4. Is the pacer not sensing heart rate in demand

mode?
Check size of R-wave. If it is too small,
increase
the ECG size.
Check to see if the pacer is turned on.
Check electrode/patient contact.
Check electrode connections.
5. Is there a noisy ECG signal?
Was the patients skin clean and dry and
excessive
hair removed prior to electrode
attachment?
Was the expiration date checked before
applying the electrodes?
Check the electrode connections.

Dry gel will have an

adverse effect
on the ECG signal.

PHILIPS HEARTSTARTER MRx:

Demand Mode Pacing (Requires ECG leads
and pads)
1. Turn the Therapy Knob to Pacer.
2. Press the Lead Select button to select the
desired lead.
3. Verify white R-wave markers appear above
or on the ECG waveform.
4. Press the Pacer Rate soft key, select the
desired number of paced pulses
per minute, and press the Menu Select button.
5. If needed, press the Pacer Output soft key,
use the Navigation buttons to
adjust the initial pacer output, and press the
Menu Select button.
6. Press the Start Pacing soft key.
7. Verify white pacing markers appear in front
of every QRS.
8. If cardiac capture is not obtained, press the

Pacer Output soft key, increase

the output until capture occurs, decrease the
output to the lowest level that still
maintains capture, and press the Menu Select
button.
9. Verify the presence of a peripheral pulse.

Fixed Mode Pacing (Can be done with pads

only)
1. Turn the Therapy Knob to Pacer.
2. Set the pacer mode to Fixed.
- Select Pacer Mode from the Main Menu.
- Select Fixed and press the Menu Select
button.
3. If using leads, press the Lead Select button to
select the desired lead.
4. Press the Pacer Rate soft key, select the
desired number of paced pulses
per minute, and press the Menu Select button.
5. If needed, press the Pacer Output soft key,

use the Navigation buttons to

adjust the initial pacer output, and press the
Menu Select button.
6. Press the Start Pacing soft key.
7. Verify cardiac capture. If it is not obtained,
press the Pacer Output soft key,
increase the output until capture occurs,
decrease the output to the lowest
level that still maintains capture, and press the
Menu Select button.
8. Verify the presence of a peripheral pulse.
NOTE: If monitoring SpO2 when pacing,
activate the Pulse alarms
to assess for peripheral perfusion through the
SpO2 transducer.