Transcutaneous pacing

  1. Here's the day I was having:
    Patient was having alternating rapid a-fib with sinus brady; up to 13 second pauses. Permanent pacer planned for next morning. Doc doesn't want to put in temporary pacer..... Patient was either complaining about shocks or getting dizzy and turning really pale during pauses.... Docs don't want to sedate for fear of causing worse bradycardia...

    I'm not new to ICU, but I'm relatively new to pacers...

    Questions: Can you tell from a rhythym strip whether the transcutaneous pacer is capturing? I didn't like the answer the EPS doc gave me which was "You can't tell from the strip, you have to feel for a pulse" That's fine unless I need to walk out of the room.

    How much and what type of sedation helps the patient tolerate this??
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    About VAC

    Joined: Oct '01; Posts: 163; Likes: 69
    RN

    10 Comments

  3. by   clarkheart
    Quote from VAC
    Here's the day I was having:
    Patient was having alternating rapid a-fib with sinus brady; up to 13 second pauses. Permanent pacer planned for next morning. Doc doesn't want to put in temporary pacer..... Patient was either complaining about shocks or getting dizzy and turning really pale during pauses.... Docs don't want to sedate for fear of causing worse bradycardia...

    I'm not new to ICU, but I'm relatively new to pacers...

    Questions: Can you tell from a rhythym strip whether the transcutaneous pacer is capturing? I didn't like the answer the EPS doc gave me which was "You can't tell from the strip, you have to feel for a pulse" That's fine unless I need to walk out of the room.

    How much and what type of sedation helps the patient tolerate this??
    The best source for me to see how well my transcutaneous pacer is capturing is checking my monitor on my biphasic defib that I'm using to pace the patient with. I usually get too much interference if I try to evaluate the 5 lead monitor that the patient is also hooked up to. I check blood pressures very closely and evaluate LOC. The ideal is to have an art line so you can be more precise on how well your perfussion is.
  4. by   candyndel
    Sounds like Sick Sinus Syndrome to me... pt needs a DDD pacemaker asap. She actually needed a TVP. I like TVPs much better, although the risk of complication is higher. The pt was very symptomatic with the pauses and a TVP requires hardly (if any) sedation. TCP is so painful...I would have insisted on the wire!! Why didnt he want one?



    Quote from VAC
    Here's the day I was having:
    Patient was having alternating rapid a-fib with sinus brady; up to 13 second pauses. Permanent pacer planned for next morning. Doc doesn't want to put in temporary pacer..... Patient was either complaining about shocks or getting dizzy and turning really pale during pauses.... Docs don't want to sedate for fear of causing worse bradycardia...

    I'm not new to ICU, but I'm relatively new to pacers...

    Questions: Can you tell from a rhythym strip whether the transcutaneous pacer is capturing? I didn't like the answer the EPS doc gave me which was "You can't tell from the strip, you have to feel for a pulse" That's fine unless I need to walk out of the room.

    How much and what type of sedation helps the patient tolerate this??
  5. by   DustinRN
    I've never had a patient with TVP or TCP. Are there no spikes on the ECG to show you when the pacemaker is firing? I've never had a patient with one so I'm just wondering.
  6. by   Dinith88
    Quote from DustinRN
    I've never had a patient with TVP or TCP. Are there no spikes on the ECG to show you when the pacemaker is firing? I've never had a patient with one so I'm just wondering.

    A 'TVP' will show spikes w/bundles the same way a permanent pacemaker does.

    A 'TCP' will (usually) show spikes and big bundly-looking things... regardless of whether or not it is 'capturing' the pt's heart. Thats the trick with TCP's and why the EP-doc told the origional poster that you'd have to feel a pulse to confirm capture. So...if you're ever pacing someone (TCP), and you see the TCP spikes 'capturing' on tele, you had best make sure as you may only be 'capturing' someones chest wall. And another tricky thing is that sometimes the discharges can produce a 'psuedo-pulse' where someone feels muscle-contractions (synchronous w/pacer discharges) and assumes it's a pulse...
    In the OP's scenario, i'd surely feel for a pulse, but would feel better going by the pt's level of conciousness...You know they're perfusing if they're still talking.

    And as far as the OP's post is concerned, if that patient were being TCP'd at any point I'd be electing that doc for a swift arse-paddling (for not placing a temp./TVP as a bridge to PPM)
    TCP is not something you can handle for too long without (or with!) sedation. If the TCP is just 'stand-by' that may be a different story...
  7. by   candyndel
    Yes, all you can see is the spike sometimes.... Remember the TCP has to permeate tissue, bone, fat, etc to get to the heart, so the mA you need to capture with is much greater than that of a TVP. mA's with a TCP can range from 60 up to 140 while the usual mA needed in a TVP is about 4 with a threshold of 2.
    So when you see the huge 'spike' of a TCP, it overpowers and obscures any other electrical impulses at that time so an actual complex (or captured beat) is not easily discernible on the monitor. (nor are the pulses easily palpable, for that matter!)

    QUOTE=DustinRN]I've never had a patient with TVP or TCP. Are there no spikes on the ECG to show you when the pacemaker is firing? I've never had a patient with one so I'm just wondering.[/QUOTE]
    Last edit by candyndel on Jun 21, '05
  8. by   Dinith88
    Quote from candyndel
    Yes, all you can see is the spike sometimes.... Remember the TCP has to permeate tissue, bone, fat, etc to get to the heart, so the mA you need to capture with is much greater than that of a TVP. mA's with a TCP can range from 60 up to 140 while the usual mA needed in a TVP is about 4 with a threshold of 2.
    So when you see the huge 'spike' of a TCP, it overpowers and obscures any other electrical impulses at that time so an actual complex (or captured beat) is not easily discernible on the monitor. (nor are the pulses easily palpable, for that matter!)

    QUOTE=DustinRN]I've never had a patient with TVP or TCP. Are there no spikes on the ECG to show you when the pacemaker is firing? I've never had a patient with one so I'm just wondering.
    [/QUOTE]

    Well put.

    And as far as the mA needed to effectively capture someone's heart, it's usually a case of 'cranking it' to the max output and bringing it down to where you're obtaining capture w/the smallest mA (rather than slowly increasing)...because TCP is most-often utilized in fairly critical/emergent situations in which you have no time to fool around with lower outputs. <It's not standard/common/acceptable to place someone on standby TCP pads and then 'test' the mA for capture threshold (for obvious reasons)>. You can imagine how uncomfortable that would be! <again speaking volumes for making the OP's doc look bad...(lazy?) as he wouldn't sedate or place a TVP>
  9. by   DustinRN
    Thanks guys/gals!
  10. by   chadash
    Quote from DustinRN
    Thanks guys/gals!
    Help! I am a CNA, and my mom has had this history of tachycardia: just all of a sudden her heart kicks into overdrive. I took her pulse the other day just on a fluke, and it was 48. I called her Dr. and left a message with the nurse, but I havent heard back. Yesterday I took it again and it was 52 (she was really angry at that moment cause I called her doctor, so it may have been up from that )
    she said it was not a problem, and that it was "racing" early.
    Did I overreact by calling?
    Last edit by chadash on Jun 29, '05
  11. by   Dinith88
    Quote from chadash
    Help! I am a CNA, and my mom has had this history of tachycardia: just all of a sudden her heart kicks into overdrive. I took her pulse the other day just on a fluke, and it was 48. I called her Dr. and left a message with the nurse, but I havent heard back. Yesterday I took it again and it was 52 (she was really angry at that moment cause I called her doctor, so it may have been up from that )
    she said it was not a problem, and that it was "racing" early.
    Did I overreact by calling?
    If your mom does not have any symptoms with this heart rate (dizziness, palpitations, etc.), it's probably nothing to worry about. On the other hand if she IS symptomatic then she surely needs seen by Doc.

    If she is on medications for her history of 'tachycardia', it could very well be the reason for the slower rate...and she is probably 'used to' these slower rates and does fine with them (meaning symptom free).
    You've posted this message on a 'transcutaneous pacemaker' discussion so i'm assuming you may be worried that she needs a pacemaker. If this is the case, i think you may be worrying unneccesarily(sp?) at this point.

    Anyway, it wont hurt to run this by her doctor so DONT feel like you've overreacted....it's his/her job after all.
  12. by   chadash
    Thanks for your reply! it is very reassuring. She has complained of being weaker lately, but not dizzy. You are so smart! she is on meds for the tachycardia, though she still pops up there from time to time. She does seem comfortable with the low heart rate, only complains when it races...
    I will keep an eye on her, she's the only mom I've got! But I won't panic

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