*Exactly* How Do You Actually Pace?

[AnthonyM83]

So, awhile back, we had a bradycardic ALOC patient from nursing home 911 call. He went into and out of PEA. Atropine didn't work, so we were going to just transport like usual. Then, I was truly impressed...a FF actually wanted to try TCP. You don't understand how huge this is that someone would actually try this in these parts.... I

I give her points for that...but then both medics who rode in with us had no idea how to actually do it. Since I was closest to the monitor (Zoll), they had me moving both dials every which way. They had me turn each dial from really low to really high until they got scared and had me go back down...I felt like 3 new EMTs had been handed a monitor to play with.

So my question is: EXACTLY how do you do the physical process of pacing? Where do you start your dials, where do you move them to, what do you look for on the screen, how do you know you've captured, etc etc.

[JPINFV]

I'll handle the captured part. When pacing you get a small vertical line called a pacer spike on the monitor. When you've reached a high enough current strength to achieve capture, the QRS complex will be paired with the pacer spike (since the monitor is now giving the signal for the heart to contract).

[AZCEP]

All devices are a bit different in how to set them up, but by and large the process if the same.

Set your current. This should be the minimum amount needed to obtain capture, but don't take all day deciding how much energy you need to use. For your transient PEA patient, I'd suggest using the maximum and leaving it there.

Set the rate. Because the idea is to accelerate the rate past the bradycardia it really makes no sense to start at 60/min. 80-90 beats per minute is the norm here.

Continue monitoring for effect. While the TCP is working do not cave to the suggestion to turn it off until you arrive at the receiving facility. Should you do this there is a very good chance you will not be able to obtain capture again.

[Asysin2leads]

Wait, so, the FF/Medic wanted to try pacing but couldn't remember how to do it? Cardiac pacing isn't just something we try for the hell of it. ACLS has pretty clear guidelines as to when to reach for the pacer and when not to, and most regional EMS protocols also spell out when to do it or not, and I was under the impression that using the cardiac pacer was a standard skill set in most paramedic services. Is the LAFD rockin' the ganja again, or what? Hee hee.

Anyway, cardiac pacing is easy and fun. First you need a patient who is unstable and bradycardic, and you should probably already have gotten in your first line drugs. 0.5 of atropine, and a dopamine or epinephrine drip if you're feeling frisky. Next, you should attach the pacer pads, which conveniently enough should also be the defib pads. I am not sure what the exact technicalities of the Zoll's monitor is, but the medic should have known, but basically you set the rate of pacing, we pace at 80 bpm but you can set it at what you want to, then you dial of the voltage until you get capture, which should look on the EKG like a pacer spike with a corresponding QRS complex, and more importantly, improvement in hemodynamic function. Our standing orders are to dial it down until you lose capture, then fine tune it to the lowest voltage setting, but so long as you have capture you should be GTG. Oh and its also good to sedate the patient before zapping them through the skin repeatedly.

[akroeze]

We set the rate at 80ppm and start at 0mA and slowly dial up until we have consistent capture then go up by another 5-10mA to ensure a good capture stays.

[AnthonyM83]

Yeah, it was LACoFD (I haven't worked with LAFD, but heard they're a bit better...big on being the best, so even if they dislike EMS, they have the drive to try to be good at it).

Anyway, actually trying this was a step up for them.

So, if the patient is at 40BPM. You wouldn't have to start slower than patient's HR, then slowly go past it? (This is one of the things they tried)

I would just set rate to 80 BPM, then start at 0mV, and slowly turn the dial up. Eventually the HR and shocking will coincide and then every shock will result in a QRS complex? Is that the idea?

Can we go over cardioversion next?

[WelshMedic]

Anthony,

You want cardioversion, you got it!

This is an actual case, a call I did about 3 weeks ago.

Male 39y/o, collapsed after sexual intercourse with his wife. Now lying naked and supine in the bathroom between the toilet and shower cubicle (boy, I so never wat to be in that position myself...)

Presentation: Pale, clammy, anxious (I'm going to die...), low BP, no pulses in extremities present. Is Alert en orientated. Complaining of extreme chest pain and dizziness (!). I pride myself on having that sixth sense in diagnosing my patients - I was already convinced this was a right sided barn door MI........my I was wrong....

We gave the patient the usual: o2, IV and made a 12 lead. I found this:. It was a wide-complex tachycardia (Vtach) with a ventricular response of 270bpm! I subsequently gave him amiodarone, but without much effect. He went down to around 230 and then just went right back up again. By this time his BP was 75/36 and he was just getting worse. So I decided to cardiovert him. It was the first time in my career that I had a reason to do so.

First I administered a low dose of Versed (2.5mg) because of his hypotension. We use the LP12 so I then placed the ECG in synchronized mode. For those of you who don't know how this works, it just means that the monitor seeks out the R-wave and marks it. When the shock is delivered, it is then delivered at this point thus reducing the risk of VF. Look for the markers I'm talking about on this video:.

The patient is then instructed that it may feel uncomfortable (understatement..). Once I did this I selected 150j on the defibrillator and pressed until the shock was given. That's also the difference between cardioversion end defibrillation, because it waits for the R-wave it does not fire instantaneously.

The patient converted back into sinus rhythm almost immediately, but did have transient ST elevations in his ECG - this is also a common phenomenon amongst these patients:See here.

Almost immediately he felt a lot better, had no more chest pain and just wanted to sleep. So would I, by the way, after having a HR of almost 300 for more than half an hour and getting Versed on top of it.

We delivered him to the local CCU for evaluation. When I was cleaning the truck out in the parking lot I came across the patient's brother. He said: "Oh, I was so worried about him. You see, I have Wolf-Parkinson White and have had an ablation last year. Could this have anything to do with it?" My reply: "Errr, go upstairs and tell them about it as quick as you like."

Well that's my story about cardioversion....I hope you enjoyed it.

WM

[AnthonyM83]

Thanks for sharing WM.

Do you need special pad placement for either TCP or Cardioversion? I heard from someone it had to be front/back for one of them...

[DirtJerZ]

I recently had a patient who was cool, pale, clammy, AMS, Hypotension with no radials or femorals, the patient was in sinus brady around 40 bpm so I immediately established an IV and gave 0.5mg atropine while my partner set up the pads, I got the fluid bolus going. We set up the pacer at a rate of 70 and got capture at 100 ma. The patient started waking up and in pain. I called the Med Control but we had already arrived at the ER(City EMS)at this point. We rushed the patient into the ER and we were ignored by the nurses, I actually said "We have a critical patient Here!" and the nurses all looked around and said "they're all critical patients!" Some nurse finally came over and we finally got a bed. they switched the machines over to theirs and checked the vitals, the patient had mass improvements so they took the pads off and the patient went unconscious and eventually coded and died. GO TEAM WOO!

[WelshMedic]

Anthony,

The way I learned was anterior/posterior for pacing and anterior for defibrillaton. I've never really questioned it, to be honest but I wil do some googling of my own this week.

WM