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Circulation - Pacing (transcutaneous)

This procedure is performed using procedural sedation which is covered separately


Bradycardia (HR <40bpm)


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


Unresponsive or unsuitable for medical therapy

Contraindications (absolute in bold)

Severe hypothermia (risk of arrythmia)


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 pacing

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

Failure (increased thoracic air or tissue)

Implanted pacemaker malfunction (if present)

Induction of ventricular fibrillation (rare)

Procedural hygiene

Standard precautions

Standard aseptic non-touch technique

PPE: non-sterile gloves


Resuscitation bay


Procedural clinician and assistant

Additional clinician dedicated to monitoring


Defibrillator (with pacing function)

Multifunction adult pads (pads that can monitor, pace and defibrillate)


Supine 30 degrees head up

Remove jewellery, shave and dry chest

Placing pads antero-posterior is preferred (precordium under breast tissue and directly posterior)

Anterior-lateral placement can be used if required (with risk of suboptimal capture)

Disable any pacemaker or defibrillator with a magnet placed over the device

Place pads away from ECG electrodes and >10cm from pacemaker or defibrillator box if present


Supplemental oxygen throughout procedure

Morphine 5-10mg IV titrated to effect

Midazolam 1-2mg IV titrated to effect

For patients in cardiovascular collapse, consider starting pacing without sedation.

Sequence (pacing)

Administer sedative and analgesic medications to manage discomfort (chest wall muscular contractions)

Turn the defibrillator on to ‘PACER’ mode

Set pacer output to 0mA

Set pacer rate to 70bpm

Increase the current by 10mA aliquots until electrical capture is achieved (QRS complex follows each pacing spike)

Increase the current by a further 10% (typical threshold currents at between 40-80mA)

Confirm mechanical capture (patient’s palpated pulse matches pacing rate)

Sequence (troubleshooting failure to pace)

Check connections and battery

Improve pad placement

Treat underlying cause (ischaemia, metabolic derangement)

Post-procedure care

Continuous ECG monitoring in a resuscitation bay

Provide ongoing pain relief

Arrange definitive treatment or transvenous pacing

Document (completion, technique, complications)


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 recommend due to risk of rhythm deterioration

Pacing is generally unsuccessful for drug-induced bradycardia

Older pacemaker defibrillators may require separate monitoring ECG electrodes

It is safe to provide CPR over insulated electrodes while pacing (1/100th power output of defibrillation)

Replace multifunction pads after eight hours of continuous pacing


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

Greater Sydney Area Helicopter Emergency Service


Please direct feedback for this procedure to


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

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