II. Indications
- Alternative to Transcutaneous Pacing
- Unstable Bradycardia (e.g. third degree AV Block)
- Prolonged transport time with higher likelihood of rhythm decompensation
-
Myocardial Infarction with new Arrhythmia (LBBB, RBBB, Type II second degree AV Block, Third Degree AV Block)
- High risk of fatal Bradycardia (up to 43%)
- However, first priority is reperfusion!
III. Advantages: Contrast with Transcutaneous Pacing
- Requires only one tenth of the delivered energy (milliamps) as Transcutaneous Pacing
- Does not require nearly the same level of sedation and analgesia as Transcutaneous Pacing
- Does not generate the significant tracing artifacts seen with Transcutaneous Pacing
IV. Technique
- Preferred Central Line sites (most direct, least tortuous courses)
- Right internal Jugular Vein (preferred)
- Left subclavian vein
- Place Catheter 6 French sheath (in Pacemaker kit)
- Use 6 French instead of 9 French standard Cordis catheter
- The larger, 9 French leaks blood and fails to allow adequate Pacemaker wire control
- Attach the plastic, accordion sheath
- Connect the sheeth hub to the catheter
- Wire threaded through the sterile sheath and into the catheter
- Test wire balloon by inserting 1.5 cc air prior to insertion (then deflate)
- Attach the pacer
- Thread the wire
- Deflate balloon
- Pass wire via sterile sheath into 6 French catheter
- Wire inserted to the second mark (20 cm)
- Advance Wire
- Turn on Pacemaker generator once tip has cleared introducer sheath
- Rate: 60-80 bpm
- Sensitivity: Asynchronous, lowest possible
- Output: 5 mA
- Some recommend setting to maximal ouput (20 mA) to start
- Decrease output once capture occurs (see below)
- Reinflate balloon
- Inflate balloon with 1.5 cc air and turn stop-cock
- Balloon reinflated to allow floating of wire into the right atrium and right ventricle
- Advance the wire to the third mark (30 cm)
- EKG Monitor (not the EKG machine or alligator clip)
- Observe for electrical and mechanical capture
- Electrical tracing will show a Pacemaker spike followed by Wide QRS (LBBB appearance)
- Heart Rate will increase from Bradycardia to pacer rate at capture
- Palpate pulse or auscultate heart sounds
- Oxygen Saturation waveform
- Bedside Ultrasound of heart
- Troubleshooting problems passing through the tricuspid valve
- Short Stature patient
- Withdraw the introducer by small increments and reattempt
- Tricuspid regurgitation pushes balloon backwards into right atrium
- Consider threading without balloon inflated
- Consider alternative access site other than internal Jugular Vein
- Subclavian line
- Femoral line
- Short Stature patient
- Turn on Pacemaker generator once tip has cleared introducer sheath
- Deflate balloon
- Open stopcock and allow balloon to deflate spontaneously (syringe fills with air)
- If capture lost, reinflate balloon and advance again
- Secure catheter and pacer
- Extend sheath to cover pacing catheter and tighten the associated valve
- Consider confirming lead placement with Bedside Ultrasound
- Adjust Pacemaker generator
- Decrease pacer output until capture is lost (typically 0.3 mA or less)
- Increase again until capture occurs and to approximately 2.5 times lowest capture threshold
- Decrease pacer output until capture is lost (typically 0.3 mA or less)
V. Safety
- Safe and effective (95% sucess rate) when performed in the emergency department for Symptomatic Bradycardia
VI. References
- Bessman in Roberts (2014) Roberts and Hedges Emergency Procedures, Elsevier, Philadelphia, p. 277-97
- Kwon and Warrington (2016) Crit Dec Emerg Med 30(9):10-11
- Orman and Bellezzo in Herbert (2016) EM:Rap 16(4): 8-9
- Sacchetti in Herbert (2017) EM:Rap 17(5): 1-2