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Circulation - Pacing (transvenous)

Emergency transvenous temporary pacing complications are common. In large hospitals this procedure is usually performed by cardiologists outside of the emergency department. Temporary pacing by emergency physicians may occasionally be necessary, but positive chronotropic drug infusions and transcutaneous pacing are preferred where possible.

Indications

Bradycardia (HR <40bpm)

and

Unstable (altered mental status, SBP <90mmHg, angina, pulmonary oedema)

and

Unresponsive or unsuitable to medical therapy or transcutaneous pacing

Contraindications (absolute in bold)

Mechanical prosthetic tricuspid valve

Severe hypothermia (risk of arrythmia)

Anticoagulation or recent thrombolysis

Alternatives

Treat precipitant (drugs, ischaemia, electrolyte abnormality)

Atropine 0.5mg intravenously, repeat after 3-5 minutes if necessary, up to a maximum of 3mg

Isoprenaline 2-10mcg/min IV, titrated according to clinical response (risk of fall in blood pressure)

Adrenaline 2-10mcg/min IV titrated according to clinical response

Transvenous cutaneous

Immediate permanent pacemaker

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Lead

Failure (dislodgement, disconnection)

Heart

Dysrhythmia (asystole, VF, VT)

Perforation

Tamponade

Chest

Vascular damage, bleeding and haematoma

Pneumothorax or haemothorax

Air embolism

Diaphragm stimulation

Infection (local and systemic)

Thromboembolism

Procedural hygiene

Standard precautions

Surgical aseptic non-touch technique

PPE: surgical mask, protective eyewear, sterile gloves, sterile gown, sterile ultrasound cover and gel

Area

Resuscitation bay

Staff

Procedural clinician, nurse assistant

Additional clinician dedicated to monitoring

Equipment

Ultrasound

Pacing generator with new batteries

ECG machine or monitor with anterior leads attached

ECG adaptor to connect pacing catheter to monitoring anterior ECG electrode

Pulmonary artery catheter or introducer sheath (usually 6Fr) and sterile sleeve

Balloon tipped bipolar pacing catheter (usually 3-5Fr, leak excluded with inflation under sterile water)

3ml syringe (air-filled)

Positioning

Position as for right internal jugular central venous catheter

Supine, on an incline with head down 15 degrees

Head slightly rotated away from puncture site

Insertion site: Between medial and lateral heads of SCM muscle, lateral to the carotid, aiming to ipsilateral nipple

Medication

10ml lignocaine 1%

Consider analgesia and sedation

Sequence (insertion and connection of pacing wire)

Insert and secure a 6Fr introducer sheath via right internal jugular vein (see internal jugular vein central venous access guide)

Attach the positive terminal of the pacing generator to the positive (proximal) catheter terminal

Attach the V2 ECG lead to the negative (distal) catheter terminal using an ECG adaptor (any V lead will work)

This forms an exploring intracardiac ECG electrode to localise the lead tip

Attach sterile sleeve to pulmonary artery catheter sheath

Insert pacing wire through sheath to 15cm depth

Inflate floatation balloon with 1.5ml air, and lock catheter stopcock leaving syringe attached

Re-advance pacing wire, noting changes on V2 to ascertain correct placement of balloon

The P waves will increase in size as the catheter tip approaches the right atrium

The QRS complex will increase in size as the catheter tip approaches the right ventricle

If the QRS complex falls in size the catheter is in the inferior vena cava (pull back to 15cm, twist and re-advance)

If catheter-induced ectopic beats are seen, withdraw the catheter slightly then re-advance after ectopy ceases

ST segment elevation will occur when the catheter tip contacts the right endocardial wall (correct placement)

Subxiphoid ultrasound can be used to demonstrate the wire in the RV, and visualise mechanical capture

Secure pacing wire when ST segment elevation is present, noting this current depth (usually 35-45cm)

Deflate balloon by releasing the stopcock to the syringe (refilling syringe)

Remove negative (distal) catheter terminal connection from the V2 lead on the ECG

Attach negative (distal) catheter terminal to the negative terminal on the pacing box

Sequence (confirmation of capture and securing pacing catheter)

Set ventricular pacing at a rate of 80bpm, output of 10mA, high sensitivity of 0.8mA (VVI demand pacing)

Turn pacer on, and assess for electrical capture (QRS complex following each pacing spike on ECG)

Assess for mechanical capture by palpating a pulse equal to the pacemaker rate

Ask patient to cough and check wire does not dislodge (loss of pacing)

Coil excess pacing catheter and secure under a large sterile dressing

Sequence (setting threshold to ensure consistent capture)

Reduce output until capture lost (may be <1mA in the optimum position), this is the threshold

Increase output to two times threshold output (usually 2-3mA)

Sequence (setting pacemaker sensitivity)

Reduce to minimum sensitivity (asynchronous mode), and ensure complete capture

Adjust sensitivity to mid position (approximately 3mA)

Decrease rate until pacing is suppressed by intrinsic rhythm

Check sensing indicator signals each native beat

Pacer fails to sense - increase sensitivity

Pacer triggered by p or t waves (over-senses) - decrease sensitivity

Once sensitivity threshold determined, set millivoltage to half that value

Post-procedure care

Chest X-ray (confirm pacing wire in RV, exclude pneumothorax)

ECG to confirm a LBBB pattern (RBBB may indicate perforation or misplacement)

Bedside ultrasound to exclude pericardial fluid and pneumothorax

Documentation (completion, technique, attempts, guidewire removal, complications)

Tips

Prophylactic pacing of patients at high risk of AV block is unlikely to be indicated in the emergency department

‘Overdrive’ pacing of tachyarrhythmia is not generally recommended due to risk of rhythm deterioration

Pacing is generally unsuccessful for drug-induced bradycardia

Inserting a semirigid wire catheter without a balloon (same method) has higher complication rates

Defibrillation and cardioversion are safe in patients with temporary pacemakers

Discussion

Tachyarrhythmia caused by digoxin or QT prolongation (excluding atrial fibrillation), might benefit from overdrive pacing (pacing at a rate 40 bpm higher than the dysrhythmia for 10 seconds unsynchronised runs).

Overdrive pacing has been used effectively in hospital, but method is not well described or validated. There is also a risk of rhythm deterioration. We do not recommend its use in emergency department without specialist cardiology input.

Prophylactic pacing of patients at high risk of AV block is unlikely to be indicated in the emergency department. We recommend that such patients be monitored in the emergency department and paced only if required.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34(29):2281-2329. doi:10.1093/eurheartj/eht150

Australian Resuscitation Council. Guideline 11.9 – managing acute dysrhythmias. East Melbourne: ARC; 2009. 11pp. Available from: https://resus.org.au/guidelines/

NSW Agency for Clinical Innovation. Transcutaneous pacing. Sydney: ACI; 2015. Available from:

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0018/380313/Transcutaneous_Pacing.pdf

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Harrigan RA, Chan TC, Moonblatt S, Vilke GM, Ufberg JW. Temporary transvenous pacemaker placement in the Emergency Department. J Emerg Med. 2007;32(1):105-111. doi:10.1016/j.jemermed.2006.05.037

Gammage MD. Temporary cardiac pacing. Heart. 2000;83(6):715-720. doi:10.1136/heart.83.6.715

Ganz LI. Temporary cardiac pacing. In: UpToDate. Waltham (MA): UpToDate. 2019 Mar 1. Retrieved Apr 2019. Available from: https://www.uptodate.com/contents/temporary-cardiac-pacing

eTG complete. Melbourne: Therapeutic Guidelines; 2018 Mar. Bradyarrhythmias (retrieved April 2019). Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=bradyarrhythmias

Murray L, Little M, Pascu O, Hoggett KA. Toxicology handbook. 3rd ed. Sydney: Elsevier Australia; 2015.

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