Trouble with transcutaneous pacer

RNKPCE · Dec 11, 2003

Did you also have the cables from the tcp machine hooked up to the patient? On our tcp you have to have the machines cables hooked up as well as the tcp pads. Not just your leads to your bedside or tele monitor.

zambezi, BSN, RN · Dec 11, 2003

31 hours of tcpacing. OUCH. Why didn't they put in a transvenous pacer? They work better anyway...IMHO

XIGRIS · Dec 18, 2003

31 hours of non capture! Wow, its a very long time. It seems to me that your patient was stable enough to have lived that long without the aid of the pacer.

Here are some tips for TCP.

1. To get a capture, you need a higher amount of output ( which is the mv in the pacemaker generator-- which is i think the crash cart defibrillator ). The reason for higher mv is because inorder for the current to stimulate the myocardium, it needs to pass by the skin, the bones and ribs to inititate the capture. So sometimes, I start my mv at 50 and go from there.

2. just like any other pacer, your QRS should be widen when the pacer captures the ventricle.

3. look for the famous spike that we are taught in school. if it is far from the ORS, increase the output.

4. look at your rate. is it lower than the desired rate of your TCU? if you set your pacer at 70, and your rate is at 60. by all means you are not pacing right. increase the output. if it is 80, wean down the rate and maybe d/c it.

5. TCP is very uncomfortable for the patient. if by al means the patient doesnt need the pacer turn it off and keep it at bedside for standby.

so hope this helps.

btw, if you are not sure and the doctor is not sure whether its capturing right, suggest transvenous and if the patient is stable enoguh. have atropine ( well, only if the are wenkebach . atropine is useless with mobits and complete block )ready at bedside.

MarkHammerschmidt · Dec 18, 2003

It's not that hard. You're pacing the patient for symptomatic bradycardia, right? Namely, their rate is low, so their BP is low. The transcutaneous pacer is gonna generate electrical artifact on whatever monitor you use - this does not mean that the patient's heart has been captured. Check her pulse. Is it at the rate the pacer is set at? Is her BP higher now? I rest my case.

Dinith88 · Dec 24, 2003

Celia, that's scarey. Those nurses should be re-educated. The patient had to endure that constant zapping for no reason at all! The nurses who let this get by for that long would do good to keep this embarassments under wraps....it's got lawsuit written all over it....

ouch.

FireMedTB · Aug 15, 2005

We recently had a patient on a TCP for 31 hrs and it never captured. This was not picked up by the nurses or the IM MD. The cardiologist picked it up and dc;d the pacer and the pt had no ill effects. Does any one have any bright ideas of how to teach the staff to recognise capture and troubleshoot?

I know this is an old thread, but I'm replying anyway, because the failure to recognize false capture is an under-recognized and under-reported problem both in EMS and in nursing. If you honestly think it couldn't happen to you, think again!

Muscle twitching artifact can do a great job of mimicking electrical capture on the monitor. Yes, it helps to look for a wide QRS with a displaced ST segment and a tall, broad, discordant T wave (like any other ventricular rhythm) but it's amazing how much false capture can mimic a true paced QRS complex.

Leave the pacer in non-demand mode, at least initially. That way, you can watch to see if the patient's underlying rhythm marches through the absolute refractory periods of the [presumed to be] paced QRS complexes. If they do, you know that you have false capture on the monitor.

I have reviewed dozens of cases of TCP, and in a frightening number of cases, the person performing the skill reported carotid, femoral, or radial pulses, even though electrical capture did not exist on the EKG strips provided. It sounds good in theory, but don't underestimate the combination of severe muscle twitching and wishful thinking! I've seen this happen to paramedics, nurses, emergency physicians, and one cardiologist. Do not trust a simple pulse check!

Confirm the presence of pulses with an instrument. Use the SpO2 monitor (or doppler) and document that you have done so.

It is common to get an increase both in the level of consciousness and the blood pressure with TCP, whether electrical capture is achieved or not! Think about it. You are shocking this person! This is not a reliable method. I have reviewed several cases where there was an increase in responsiveness and an increase in pressure, even though the EKG showed false capture!

Always use the anterior/posterior placement of the combi-pads when you perform TCP. There will be less transthoracic resistance and you can place the left ventricle directly between the pads. If the patient is peri-arrest or severely compromised, start out at maximum current (200 mA) and work BACKWARDS until capture is lost, then go back up until you gain capture again. That way you will have a baseline for comparison and it will be obvious when capture is lost.

Remember, the most common reasons for failure to achieve electrical capture in a patient who is not in full arrest is 1.) poor pad placement or skin preparation, or 2.) insufficient mA. I hope this helps!

Best,

Tom B.