7.

Mechanical and Electrical Capture

When the hearts intrinsic pacemaker fails, an electronic device called a pacemaker is used to initiate
electrical impulses. A pacemaker is a device that uses electrical stimulus via a lead wire system to the
heart muscle to cause depolarization of the myocardium. There are two main types of artificial
pacemakers, permanent and temporary. In the ED, nurses will work with temporary non invasive
pacemakers in emergent situations, as they can be rapidly initiated to stabilize the patients rhythm
and allow time to plan further care.
Transcutaneous Pacing
When the electrical conduction of the heart is abnormal, transcutaneous pacing (TCP) can be
used to temporarily restore electrical activity of the heart (Craig, 2006). Other names for TCP include
non-invasive cardiac pacing, external cardiac pacing, precordial cardiac pacing, temporary pacing and
external transthoracic pacing (Proehl, 2009).
Indications for TCP include the following cardiac arrhythmias:
o For symptomatic bradycardias unresponsive to pharmacologic therapy;
o For symptomatic second and third degree heart block.
(Viha, 2011).
Contraindications for performing TCP are:
o Misinterpreting a fine ventricular fibrillation as asystole may lead to pacing when
defibrillation is needed
o Severe hypothermia because the bradycardia may be physiological result of a decreased
metabolic rate
o Prolonged bradyasystolic cardiac arrest (>20 min) because the chance of success is low
(Proehl, 2009).
It is important to prepare the patient prior to the procedure by explaining the purpose of TCP and
what can be expected. Explain that it will involve some discomfort, and that you will be administering
medication to provide comfort and help to relax. Next place the patient into supine position and
expose the chest. Clip excessive body hair instead of shaving as shaving may create tiny nicks in the
skin, causing pain and irritation. Position the electrodes. Provide sedative. Follow the steps outlined by
your health authority.
(Craig, 2006).
Pacing
When preparing to pace, a machine (such as the lifpak 12 in Viha) is connected to the
electrodes located on the patients chest. The pacing rate is usually between 60-100 beats per minute.
An output (mA) is set to zero and the machine is turned on. As the current is increased with muscles of
the chest wall will contract with each impulse and a pacing spike will appear on the ECG.
In Viha the ED nurse will follow the steps outlined in the policy/ procedure in Appendix A, included as
attachment to this post.

Mechanical Capture

Electrical Capture

Mechanical capture is myocardial

contraction and is evidenced by a
pulse and signs of improved cardiac
output. Signs of improved cardiac
output include a palpable pulse, rise in
blood pressure, improved level of
consciousness, improved skin color
and temperature.

Electrical capture occurs when a pacing

stimulus leads to depolartization of the
ventricles and is confirmed by ECG
changes displayed on the monitor.

Assess the patient for mechanical

capture by palpating a pulse. A
Doppler, a pulse oximeter or both may
be useful in assisting to identify and
confirm the mechanical capture.

The capture threshold is determined by

turning on the pacing machine. Beginning
at zero milliampules (mA), increase the
output until the electrical capture is seen

Electrical capture is evidenced by a wide

QRS complex (>0.12 msec) and a broad T
wave following the pacing artifact. This
means that the pacing

Document a mechanical capture with

vital signs.

Capture threshold usually ranges from 4080mA.

Maintenance pacing outputs should be set

about 10% above the threshold.

Hypoxia, acidosis, pericardial effusion, and

tamponade may lead to higher thresholds

The identification of electrical capture

may be difficult in the presence of ECG
signal distortion. Positioning the ECG leads
as far away as possible from the pacing
leads can minimize the distortion.

Document the mechanical capture with a

rhythm strip indicating the pacemaker
settings.
(Del
Monte,
2009)

After achieving an electrical capture with the pacemaker, always check for a pulse. A palpable
pulse confirms the presence of a mechanical response of the heart to the paced QRS complex (ie.
Contraction of the myocardium). Both mechanical and electrical capture must occur to benefit the
patient.
11. Atropine in ACLS

ATROPINE
Anticholinergic drug
Use:

First drug used to treat bradycardia in

the bradycardia ACLS algorithm.
Effect:

Increases the firing of the SA Node by

blocking the action of the vagus nerve
on the heart resulting in increased
heartrate.
Cautions:

Should be used cautiously in the

presence of myocardial ischemia and
hypoxia since it increases oxygen
demand of heart and can worsen
ischemia.
Dosage:

Maximum: 0.04mg/kg or 3mg

In Bradycardia: 0.5mg q3-5min

(America Heart Association, 2011).
References
American Heart Association. (2011). ACLS Principles and Practice. Dallas: American Heart Association.
Craig, K. (2006). How to provide transcutaneous pacing. Nursing, 36, 22-23. Retrieved from
http://journals.lww.com/nursing/fulltext/2006/04003/how_to_provide_transcutaneous_pacing.7.aspx
Del Monte, L. (2009). Educational series: Non invasive pacing what you should know. Mississauga,
Ontario: Physio Control. Retrieved from http://www.physio-control.com/uploadedfiles/learning/clinicaltopics/noninvasivepacing_whatyoushouldknow.pdf
Proehl, J. (2009). Emergency nursing procedures 4th ed. St. Louis, Missouri: Elsevier.
Viha (2011). Inter-professional practice & clinical standards procedure: Transcutaneous (non invasive)
pacing using the lifepak 12. Retrieved from https://intranet.viha.ca/pnp/pnpdocs/transcutaneous-noninvasive-pacing-using-lifepak-12.pdf