Download Transcutaneous Cardiac Pacing

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Hospital of the University of Pennsylvania
Clinical Practice
Policy/Procedure
KEYWORDS:
NURSING
4B-04-07
Nursing Practice
Manual
Transcutaneous Cardiac Pacing
Page 1 of 8
POLICY
Cardioversion
Defibrillation
Epicardial Pacemaker
External Pacemaker
HeartStart MRx
HeartStart XL
Permanent Pacemaker
Transthoracic Pacemaker
Transvenous Pacemaker
Transcutaneous pacing is a method of stimulating the myocardium
through the chest wall via two large pacing electrodes. The use of a
transcutaneous pacemaker may be initiated by an Emergency
Department, Adult Intensive Care Unit or Intermediate Care Unit
Registered Nurse for cardiac pacing as indicated below, as an
alternative to endocardial stimulation. The nurse will initiate this
procedure when prescribed by a physician/NP/PA. On general care
units, the physician/NP/PA will initiate and manage this therapy. The
physician/NP/PA will stay with the patient as an urgent transfer to a
higher level of care is arranged.
REFER TO:
SCOPE
1-12-11 Administration of
Moderate Sedation for
Diagnostic or Therapeutic
Intervention
All Registered Nurses in the Emergency Department, Adult Intensive
Care and Intermediate Care Units.
BCC-01-02 Defibrillation
A.
Transcutaneous pacing is indicated in patients with
hemodynamically unstable bradycardias unresponsive to
pharmaceutical intervention.
B.
Transcutaneous pacing is most useful in those patients in
whom the slow heart rate is the most likely cause of the
inadequate perfusion.
C.
Bradycardia resulting from inadequate circulating volume or
hypoxia is NOT managed by transcutaneous pacing (e.g.,
hypothermia, hypovolemia, hypoxia, shock).
D.
Transcutaneous pacing is indicated in high degree heart block:
Mobitz type II, second degee block or third degree block.
E.
Transcutaneous pacing is NOT recommended for asystole or
INDICATIONS
BCC-01-03 Synchronized
Cardioversion
FORMS:
Code Recording Form
135000-3
Sedation/Analgesia
Monitoring Flowsheet
Page1
HUP-105A-2
Page2
HUP-105B-2
PEA. Begin CPR.
SUPPLIES
A.
Transcutaneous pacemaker (defibrillator/AED) with monitor: Philips HeartStart MRx or HeartStart
XL or Agilent heartstream XL.
HUP
Clinical Practice
Policy/Procedure
Hospital of the University of Pennsylvania
NURSING
4B-04-07
Nursing Practice
Manual
Transcutaneous Cardiac Pacing
Page 2 of 8
Philips
HeartStart XL
Philips
HeartStart MRx
Agilent
heartstream XL
HUP
Clinical Practice
Policy/Procedure
Hospital of the University of Pennsylvania
NURSING
4B-04-07
Nursing Practice
Manual
Transcutaneous Cardiac Pacing
Page 3 of 8
B.
Hands free cable.
C.
Hands free pacing pads: “ConMed Padpro Defibrillation/Pacing/Cardioversion/Monitoring
Electrodes": Lawson # 145327
D.
Electrocardiogram (ECG) cable: “3 lead cable”: Lawson #204335
E.
ECG electrodes: “EKG Q-Tracer”: Lawson #124542
F.
Monitor recorder paper: “Medi-trace paper”: Lawson #100849
G.
Advanced cardiac life support (ACLS) equipment.
H.
Sedatives or analgesics as indicated.
PROCEDURE
A.
B.
Preparation
1.
Explain procedure to patient or family member as necessary. Inform the patient of
potential sensations and that sedation may be necessary.
2.
Verify the patient’s identity using two unique identifiers.
3.
Verify that informed consent has been obtained in non-emergency situations.
4.
Perform hand hygiene and apply gloves.
5.
Obtain baseline vital signs.
6.
Assess patients pain status and administer analgesics and/or sedation as indicated and
prescribed.
7.
Prepare the patient's chest and back as needed by clipping excess hair. Do not shave.
Connection
1.
Turn power to external pacing unit on.
NOTE: Note the ECG cannot be slaved off the bedside monitor. The pacing output will
destroy the bedside monitor.
2.
Place ECG leads on the patient and connect leads to the proper cable. Select a lead to
display a clear ECG waveform with an upright R wave.
3.
Securely connect pacing electrodes to pacing cable.
4.
Peel off protective covering from pacing electrodes and place pacing electrodes on the
patient in either anterior/lateral position or anterior/posterior position. The electrodes
should not be placed over wires, drains, dressings, ECG electrodes, implanted
HUP
Clinical Practice
Policy/Procedure
Hospital of the University of Pennsylvania
NURSING
4B-04-07
Nursing Practice
Manual
Transcutaneous Cardiac Pacing
Page 4 of 8
cardioverters/defibrillators, pacemakers, or medication patches. Do not place pads over
open incisions, cuts, sores, or metal objects. See images 3 and 4.
Image 3: Anterior/lateral lead placement:
Anterior/lateral placement:
The negative electrode is
placed on the left lateral
chest over the fourth
intercostal space in the midaxillary line. The positive
electrode is placed on the
anterior right in the
subclavicular area.
Image 4: Anterior/posterior lead placement:
Anterior/posterior placement:
The negative lead is placed
on the left anterior chest,
about halfway between the
xiphoid process and the left
nipple with the upper edge of
the electrode just below the
nipple line. The positive
lead is placed on the left
posterior chest just below
the scapula and lateral to the
spine.
Note: In female patients, position the negative electrode under the breast.
C.
Initiate Pacing
1.
Print a rhythm strip of the patient’s baseline rhythm.
2.
Select the pacing rate as determined by the physician/NP/PA. The rate range is typically
60 to 100 beats/min to maintain an adequate cardiac output.
HUP
Clinical Practice
Policy/Procedure
D.
Hospital of the University of Pennsylvania
NURSING
4B-04-07
Nursing Practice
Manual
Transcutaneous Cardiac Pacing
Page 5 of 8
3.
Select the desired mode of pacing, either "demand" or "fixed" mode.
•
Demand: This mode of pacing uses the sensing function to pace. In the
demand mode the pacemaker will "sense" the patient's intrinsic rate and will only
pace when the patient's own heart rate drops below the preset rate set on the
transcutaneous pacemaker.
•
Fixed: In this mode the pacer will pace at the set rate independent of the
patient's own rate. The use of this mode is rare.
4.
Press stop/start button.
5.
Set current output (mA) as follows:
Set pacer to demand mode. Increase mA from minimum setting until capture is achieved
(indicated by a widened QRS, > 0.12 msec, and broad T wave after each pacer spike).
Maintenance pacing outputs should be set at approximately 10 mA above the threshold.
NOTE: milliampere (mA) is the amount of electricity sent through the pacing pads in order
to stimulate the heart.
Determining Capture and Optimal Threshold
1.
Determining Capture: It is important to recognize when stimulation has produced a
ventricular response. Ventricular response is normally characterized by suppression of
intrinsic QRS and production of an ectopic QRS complex and T wave. Capture can also
be confirmed by auscultation and by palpation of the pulse.
a.
Auscultate and/or palpate for a pulse to ascertain mechanical capture. It is safe
to touch the patient while pacing. Refrain from touching the gelled portion of the
hands free pacing pad. A minor electrical shock hazard exists. Observe the
patient for evidence of improved perfusion. Skeletal muscle twitching should be
expected but is not an indication of pacing capture.
b.
If electrical and mechanical capture/pulse is obtained then check for a blood
pressure. It is often difficult to assess the pulse or blood pressure during pacing
due to muscle contractions. Using the right side of the body for pulse and BP
assessments may be helpful.
c.
A pulse oximeter is a powerful tool when used in conjunction with the pacer/ECG
monitor for confirming capture because both mechanical and electrical activities
can be measured. ECG alone is not enough to verify that the patient's heart is
providing cardiac output.
d.
Patients response to pacing must be verified by signs of improved cardiac output,
such as: a palpable pulse rate the same as the rate which paced pulses are
being delivered, a rise in blood pressure, and/or improved skin color.
e.
If patient's mental status improves then physician/NP/PA may order sedation for
patient discomfort secondary to muscular contractions of the chest wall. Use
Sedation/Analgesia Monitoring Flowsheet Page1 HUP-105A-2 Page2 HUP105B-2.
HUP
Hospital of the University of Pennsylvania
Clinical Practice
Policy/Procedure
1.
NURSING
4B-04-07
Nursing Practice
Manual
Transcutaneous Cardiac Pacing
Page 6 of 8
HUP Nursing Policy Administration of Sedation/Analgesia 1-12-11
Capture
2.
E.
Determining Optimal Threshold: The ideal output current (mA) is the
lowest value that will maintain capture. This is usually about 10% above
threshold.
Trouble Shooting Transcutaneous Pacing
If the pacemaker spike is not in front of each QRS complex, then one of two problems may exist:
1.
Failure to Capture: Failure to obtain capture occurs in demand and fixed mode.
Increasing the OUTPUT (mA) may obtain capture. Be sure the pads have good skin
contact. Check for correct pad placement.
Failure to Capture
2.
Undersensing: This problem occurs in demand mode only and is seen when the
pacemaker discharges immediately after the patient's own QRS complex (the discharge
occurs in the refractory period of the heart). In this case, the pads are not sensing the
patient's heartbeat. Select a different monitoring lead or reposition the pads. Fixed
pacing may be indicated.
HUP
Clinical Practice
Policy/Procedure
Hospital of the University of Pennsylvania
NURSING
4B-04-07
Nursing Practice
Manual
Transcutaneous Cardiac Pacing
Page 7 of 8
Undersensing
F.
G.
Post Procedure Monitoring and Care
1.
Provide continuous cardiac monitoring.
2.
Reassess the patient’s comfort level and toleration of the interventions.
3.
Obtain vital signs at least hourly.
4.
Document the procedure and patient response per unit policy.
5.
Consider transfer of patient to higher level of care.
Complications with Transcutaneous Pacing
1.
VF will not respond to pacing. It requires immediate electrical defibrillation.
2.
Pulseless electrical activity (PEA) may occur following prolonged cardiac arrest or in
other disease states with myocardial depression. In such instances, pacing may produce
ECG response without effective mechanical contractions (PEA).
3.
In presence of generalized hypoxia, myocardial ischemia, cardiac drug toxicity,
electrolyte imbalance, and other cardiac diseases, pacing may evoke repetitive
responses, tachycardia, or fibrillation. Defibrillation should always be readily available
and extra caution is needed to keep stimulus amplitude just above threshold.
4.
Pacing by any method tends to inhibit intrinsic rhythm. Abrupt cessation of pacing,
particularly at rapid rates, can cause ventricular standstill and can be avoided by
gradually turning down the pacing rate until an intrinsic QRS rhythm emerges.
5.
The transcutaneous pacemaker may cause discomfort of varying intensity, which can be
severe and preclude its continued use in conscious patients; unavoidable skeletal muscle
contraction may be troublesome in very sick patients and may limit continuous use to a
few hours. Erythema of the skin under the electrodes often occurs but is inconsequential.
HUP
Hospital of the University of Pennsylvania
Clinical Practice
Policy/Procedure
NURSING
4B-04-07
Nursing Practice
Manual
Transcutaneous Cardiac Pacing
Page 8 of 8
6.
The transcutaneous pacemaker may cause skin breakdown.
7.
This pacer is not appropriate for connection to internal pacer electrodes in contact with
the myocardium.
8.
Avoid touching the gelled area of the electrode while pacing. A minor electrical shock
hazard exists.
H.
Defibrillator Controls. Please see HUP Nursing Policy BCC-01-02 Defibrillation.
I.
Cardioversion and Defibrillation.
Cardioversion.
Please see HUP Nursing Policy BCC-01-03 Synchronized
REFERENCES
American Heart Association (AHA). (2005). American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care. Circulation, 112 (Suppl IV).Available online at
www.circulationaha.org
Best practices: Evidence-based nursing procedures Lippincott Williams & Wilkins, 263. Accessed
12/2010.
Mosby’s Online Nursing Skills Resource: Transcutaneous Cardiac Pacing. Accessed 12/2010.
HeartStart MRx
HeartStart XL
Agilent Hearty Steam XL
REVIEWS/APPROVALS
HUP Nursing Practice Committee
Supersedes:
“Transcutaneous Pacemaker”, (General Care Practice Manual), March, 1998; December
2003. “Transcutaneous Pacemaker", (ICU Practice Manual) 12/95. “Transcutaneous
Pacemaker", (Nursing Practice Manual) December 1, 2006
Effective Date: December 30, 2011
Disclaimer
Any printed copy of this policy is only as current as of the date it was printed; it may not reflect
subsequent revisions. Refer to the on-line version for most current policy. Use of this document is limited
to University of Pennsylvania Health System workforce only. It is not to be copied or distributed outside
the institution without administrative permission.