Transcutaneous Pacing

Aka: Transcutaneous Pacing, Temporary External Cardiac Pacing

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II. Indications

  1. Refractory Unstable Bradycardia
  2. Third Degree Atrioventricular Block
  3. Torsades de Pointes (Overdrive Pacing)

III. Precautions

  1. Transcutaneous Pacing is a temporizing measure only until definitive transvenous pacing can be achieved

IV. Technique

  1. Disable implanted Defibrillator if present
    1. Apply magnet to prevent inappropriate shocks during pacing
  2. Prepare skin
    1. Remove transdermal patches and other devices from skin surface
    2. Hair removal (use hair trimmers instead of razor to prevent skin nicks)
    3. Avoid using Rubbing Alcohol and other flammable liquids to prepare site
    4. Dry Skin site
  3. Apply pacer pads (Defibrillator/cardioversion pads) in Anterior-Posterior Positioning
    1. Anterior-posterior position is more likely to achieve capture than anterior-lateral position
    2. If anterior-lateral position is used, lateral pad should be placed over the lateral chest lower ribs
    3. Moayedi (2022) Resuscitation 181:140-146 +PMID: 36410605 [PubMed]
    4. Moayedi (2022) Circulation 146(14):1103-4 +PMID: 36191069 [PubMed]
  4. Connect pads to monitor
    1. Modern pacer pads (since 2020) sense and pace (do not require ekg leads)
    2. Older pacer pads require separate ekg lead inputs for sensing
  5. Turn on the pacing device and select pacing function
    1. Confirm that pacer is detecting underlying cardiac activity (e.g. digital mark above QRS Complex)
  6. Start Procedural Sedation and Analgesia (current >50 mA is intolerable without sedation)
  7. Turn pacing rate up to 60 bpm or (>30 beats per minute above the patient's intrinsic Heart Rate)
  8. Current/Amperage
    1. Current of 50 to 100 mA is usually required
    2. Awake patients
      1. Set the current starting at 10 mA and increase in 10 mA intervals until capture is indicated on the monitor
      2. Increase current 10 mA above the capture threshold
    3. Henodynamically Unstable Patients
      1. Start at high amperage (>=80 mA) and titrate down until capture is lost
      2. Increase current 10 mA above the capture threshold
  9. If capture is not reached by current of 120 to 130 mA, stop, reposition pads, and restart at 70 mA
  10. Confirm capture by checking patient's pulse or POCUS Chest
    1. Pulse Oximeter may register a false pulse due to Muscle Twitches despite lack of cardiac capture

V. Adverse Effects

  1. Pain (Muscle stimulation, skin irritation)
    1. Requires Procedural Sedation and Analgesia
  2. Soft tissue Burn Injury (and other skin irritation)
    1. Prepare pacing sites well (hair removal, dry site)
  3. Failure to capture
    1. Anteroposterior pad placement is typically most effective
  4. Dysrhythmia

VI. Resources

  1. Transcutaneous Pacing (Nickson, Life in the Fastlane)
    1. https://litfl.com/transcutaneous-pacing/
  2. Transcutaneous Pacing (Open Anesthesia)
    1. https://www.openanesthesia.org/transcutaneous_pacing/

VII. References

  1. Moayedi and Swaminathan in Swadron (2023) EM:Rap 23(5): 8-9
  2. Tycynska (2025) Crit Dec Emerg Med 39(8): 4-15
  3. Warrington (2026) Crit Dec Emerg Med 40(10): 20-1

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