Download Using an External (Transcutaneous) Pacemaker

Using an External (Transcutaneous) Pacemaker
Goal: It is applied correctly without adverse effect to the patient and the patient regains
signs of circulation, including the capture of at least the minimal set heart rate.
1. If patient is responsive, explain the procedure to the patient. Explain that it involves
some discomfort and that you’ll administer medication to keep him comfortable and help
him relax. Perform hand hygiene. Check the patient’s identification, if not an emergency
situation.
2. Close curtains around bed and close door to room if possible.
3. If necessary, clip the hair over the areas of electrode placement. However, do not
shave the area.
4. Attach cardiac monitoring electrodes to the patient in the lead I, II, and III positions.
Do this even if the patient is already on telemetry monitoring. If you select the lead II
position, adjust the LL (left leg) electrode placement to accommodate the anterior pacing
electrode and the patient’s anatomy.
5. Attach the patient monitoring electrodes to the ECG cable and into the ECG input
connection on the front of the pacing generator. Set the selector switch to the MONITOR
ON position.
6. Note the ECG waveform on the monitor. Adjust the R-wave beeper volume to a
suitable level and activate the alarm by pressing the ALARM ON button. Set the alarm
for 10 to 20 beats lower and 20 to 30 beats higher than the intrinsic rate.
7. Press the START/STOP button for a printout of the waveform.
8. Apply the two pacing electrodes. Make sure the patient’s skin is clean and dry to
ensure good skin contact. Briskly rubbing the skin with your hand before placing the
electrodes may improve monitor signal quality. Pull the protective strip from the
posterior electrode (marked BACK) and apply the electrode on the left side of the
thoracic spinal column, just below the scapula.
9. Apply the anterior pacing electrode (marked FRONT), which has two protective strips:
one covering the gelled area and one covering the outer rim. Expose the gelled area and
apply it to the skin in the anterior position, to the left side of the sternum in the usual V2
to V5 position, centered close to the point of maximal cardiac impulse. Move this
electrode around to get the best waveform. Then expose the electrode’s outer rim and
firmly press it to the skin.
10. Prepare to pace the heart. After making sure the energy output in milliamperes (mA)
is on 0, connect the electrode cable to the monitor output cable.
11. Check the waveform, looking for a tall QRS complex in lead II.
12. Check the selector switch to PACER ON. Select synchronous (demand) or
asynchronous (fixed-rate or nondemand) mode, per medical orders. Tell the patient he
or she may feel a thumping or twitching sensation. Reassure the patient you will
provide medication if the discomfort is intolerable.
13. Set the pacing rate dial to 10 to 20 beats higher than the intrinsic rhythm. Look for
pacer artifact or spikes, which will appear as you increase the rate. If the patient does not
have an intrinsic rhythm, set the rate at 80 beats/minute.
14. Set the pacing current output (in milliamperes [mA]). For patients with bradycardia,
start with the minimal setting and slowly increase the amount of energy delivered to
the heart by adjusting the OUTPUT mA dial. Do this until electrical capture is
achieved: you will see a pacer spike followed by a widened QRS complex and a tall
broad T wave that resembles a premature ventricular contraction.
15. Increase output by 2 mA or 10%. Do not go higher because of the increased risk of
discomfort to the patient.
16. Assess for mechanical capture: Presence of a pulse and signs of improved cardiac
output (increased blood pressure, improved level of consciousness, improved body
temperature).
17. For patients with asystole, start with the full output. If capture occurs, slowly decrease
the output until capture is lost, then add 2 mA or 10% more.
18. Secure the pacing leads and cable to the patient’s body.
19. Monitor the patient’s heart rate and rhythm to assess ventricular response to pacing.
Assess the patient’s vital signs, skin color, level of consciousness, and peripheral pulses.
Take blood pressure in both arms.
20. Assess the patient’s pain and administer analgesia/sedation as ordered to ease the
discomfort of chest wall muscle contractions.
21. Perform a 12-lead ECG and perform additional ECGs daily or with clinical changes.
22. Continually monitor the ECG readings, noting capture, sensing, rate, intrinsic beats,
and competition of paced and intrinsic rhythms. If the pacemaker is sensing correctly, the
sense indicator on the pulse generator should flash with each beat.
23. Perform hand hygiene.