Temporary Cardiac Pacing

Quick Answer

Transcutaneous pacing (TCP) is the immediate, non-invasive emergency intervention for hemodynamically unstable bradycardia unresponsive to atropine. It serves as a bridge to transvenous pacing (TVP), which provides reliable, sustained cardiac output support.

Critical Actions

1. Assess hemodynamic stability (hypotension, altered mental status, chest pain, heart failure)
2. Administer atropine 1 mg IV (max 3 mg) - if ineffective, proceed to pacing
3. Initiate TCP immediately (rate 60-80 bpm, output 50-100 mA)
4. Confirm mechanical capture (palpable pulse, BP improvement) - NOT just electrical capture
5. Prepare for TVP if TCP fails or prolonged support needed
6. Address reversible causes (hyperkalaemia, ischaemia, drug toxicity)

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ACEM Exam Focus

Written Examination (SAQ)

Expect questions on:

• Indications for temporary pacing vs medical management
• Comparison of transcutaneous vs transvenous pacing techniques
• Complications of temporary pacing and their management
• ECG interpretation of paced rhythms (capture vs non-capture, undersensing, oversensing)
• Access site selection (femoral vs internal jugular vs subclavian)

OSCE Examination

Likely stations:

• Procedure station: Performing TCP or assisting with TVP
• ECG interpretation: Identifying paced rhythms and complications
• Resuscitation scenario: Managing unstable bradyarrhythmia with pacing
• Communication: Explaining pacing need to patient/family

Viva Domains

• Indications and contraindications
• Technical aspects of lead placement
• Capture and sensing principles
• Complication recognition and management
• Transition to permanent pacing

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Key Points

1. TCP is first-line for unstable bradycardia - rapid, non-invasive, bridge to TVP
2. Confirm mechanical capture by palpable pulse or arterial waveform, not just electrical capture on ECG
3. TV preferred access: Right internal jugular offers straightest path to right ventricle, lowest displacement rate
4. Complication vigilance: Monitor for perforation (tamponade), lead displacement, infection, pneumothorax
5. Limit TCP duration: Causes skin burns, patient discomfort, unreliable capture beyond 24-48 hours
6. Check reversible causes: Hyperkalaemia (PMID 31934005), ischaemia, drug toxicity before permanent pacing
7. Ultrasound guidance: Significantly improves TVP success, reduces complications (PMID 30526017)

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Indications

Absolute Indications (Immediate Pacing Required)

Relative Indications (Consider Pacing)

• Asymptomatic complete heart block with inferior MI (may deteriorate)
• New bifascicular block (RBBB + LAFB/LPFB) with anterior MI
• Mobitz I AV block with haemodynamic instability
• Symptomatic bradycardia awaiting permanent pacemaker implantation
• Drug-induced bradyarrhythmia unresponsive to pharmacotherapy

When to Consider TCP vs TVP

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Contraindications

Absolute Contraindications

Relative Contraindications

• Severe tricuspid regurgitation - may complicate TVP lead placement
• Prosthetic tricuspid valve - may preclude RV lead placement
• Coagulopathy (INR greater than 1.5, platelets below 50) - TVP risk increased
• Active infection at access site - consider alternative site
• Morbid obesity - TCP may fail due to high transthoracic impedance

Risk-Benefit Considerations

• Asystole: TCP rarely effective (below 15% survival), consider patient prognosis before proceeding (PMID 16418086)
• Elderly patients: Higher risk of TVP complications, but symptomatic bradycardia still warrants treatment
• Renal failure: Bleeding risk elevated, consider correction before TVP
• COPD: TCP less effective due to hyperinflated lungs increasing transthoracic impedance

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Anatomy

Vascular Access Sites

Surface Landmarks

Right Internal Jugular

• Located lateral to the carotid artery at the apex of the triangle formed by:
  • Sternocleidomastoid muscle (sternal and clavicular heads)
  • Clavicle inferiorly
• Use ultrasound to identify: Carotid artery (pulsatile, non-compressible) lateral to IJ vein (compressible, no pulsation)

Subclavian

• Infraclavicular approach: 2 cm below the midpoint of the clavicle
• Aim towards the suprasternal notch
• Landmarks may be difficult in obesity or previous radiation therapy

Femoral

• Located medial to the femoral artery in the femoral triangle
• Identify: Femoral artery (midpoint between ASIS and pubic symphysis) lateral to femoral vein

Deep Anatomy

Right Internal Jugular Path

Skin → Subcutaneous tissue → Platisma muscle → Carotid sheath
→ IJ vein (lateral to carotid) → Brachiocephalic vein → Superior vena cava
→ Right atrium → Right ventricle (apex)

Subclavian Path

Skin → Pectoralis major → Clavicle → Subclavius → First rib
→ Subclavian vein → Brachiocephalic vein → SVC → Right atrium → RV apex

Danger Zones

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Equipment

Transcutaneous Pacing (TCP)

Transvenous Pacing (TVP)

Essential Equipment

Optional Equipment

Equipment Sizing

Adult Pacing Catheter

Paediatric Pacing

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Preparation

Patient Preparation

1. Explain procedure to patient/family (risks, benefits, alternatives)
2. Obtain informed consent if patient has capacity and time permits
3. Position patient: Supine with Trendelenburg (15-20°) for IJ/Subclavian, supine flat for femoral
4. Apply monitoring: Continuous ECG, pulse oximetry, BP, capnography if sedated
5. Establish IV access: At least one large-bore peripheral line
6. Pre-procedure checks:
   • Verify coagulation status (INR, platelets)
   • Check electrolytes (especially potassium - correct hyperkalaemia first)
   • Review baseline ECG for underlying rhythm
   • Confirm pacing equipment function and battery backup

Operator Preparation

1. Standard precautions (PPE): Gloves, gown, mask, eye protection
2. Hand hygiene before sterile preparation
3. Equipment check: Test pacing generator, verify cable connections
4. Assistance arranged: At least one nurse for monitoring and assistance
5. Backup plan identified:
   • Emergency cart available
   • Defibrillator pads on patient
   • Airway equipment ready
   • Immediate cardiology consult

Site Preparation

1. Sterile technique: Full barrier precautions for TVP
2. Skin preparation: Chlorhexidine 2% in alcohol (allow to dry completely)
3. Draping: Full sterile drape for TVP, maintain pad contact for TCP
4. Time-out: Confirm patient, procedure, site, and equipment

Positioning

TCP Positioning

• Anterior-posterior: Anterior pad (precordial), posterior pad (left scapula) - PREFERRED
• Anterior-lateral: Anterior pad (precordial), lateral pad (left axillary line) - alternative

TVP Positioning

• Patient: Supine with Trendelenburg (15-20°) for IJ/Subclavian access
• Operator: Standing at head of bed for IJ, at shoulder for subclavian
• Assistant: Opposite side for monitoring and equipment
• Patient head: Turned slightly away from access site (for IJ)

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Procedure Steps

Transcutaneous Pacing (TCP)

Step 1: Initial Assessment and Preparation

• Assess patient's hemodynamic stability and mental status
• Confirm bradyarrhythmia on ECG
• Check for reversible causes (hyperkalaemia, ischaemia, drug toxicity)
• Administer atropine 1 mg IV (may repeat up to 3 mg total) (PMID 30315664)
• If no response, proceed immediately to TCP

Step 2: Apply Pacing Pads

• Clean and dry chest wall thoroughly
• Apply anterior pad:
  • "Anterior-posterior: Over left precordium (V2-V3 position)"
  • "Anterior-lateral: Over left precordium"
• Apply posterior pad:
  • "Anterior-posterior: Over left scapula (PREFERRED - better capture, lower current needed)"
  • "Anterior-lateral: Over left axillary line at same level as anterior pad"
• Ensure good skin contact and pad adhesion

Step 3: Connect and Initiate Pacing

• Connect pads to pacing unit
• Set initial parameters:
  • "Rate: 60-80 bpm (start at 60, titrate to MAP greater than 65 mmHg)"
  • "Output: 0 mA initially"
  • "Sensitivity: OFF (fixed-rate pacing)"
  • "Mode: Asynchronous (fixed-rate)"
• Gradually increase output from 0 mA, observing ECG
• Look for pacing spike followed by wide QRS (greater than 0.16s) and tall T-wave

Step 4: Confirm Capture

• Electrical capture: Pacing spike followed by QRS complex and T-wave
• Mechanical capture: Palpable pulse or arterial waveform following paced QRS
• CRITICAL: Electrical capture without mechanical capture is ineffective
• Confirm mechanical capture by:
  • Palpating femoral or carotid pulse
  • Observing arterial waveform
  • Assessing blood pressure improvement
• Typical capture threshold: 50-100 mA (average 70-80 mA) (PMID 10566311)

Step 5: Optimize and Monitor

• Adjust rate to achieve MAP greater than 65 mmHg or symptomatic improvement
• Reduce output to 10-20% above capture threshold to minimize discomfort
• Provide sedation/analgesia for conscious patients:
  • Fentanyl 25-50 mcg IV aliquots
  • Midazolam 1-2 mg IV aliquots
  • Ketamine 0.5-1 mg/kg IV (alternative)
• Monitor continuously:
  • Continuous ECG for rhythm and capture
  • Blood pressure every 5 minutes initially
  • Pulse oximetry and capnography if sedated
  • Skin condition under pads every 1-2 hours

Step 6: Transition or Troubleshooting

• If mechanical capture not achieved despite maximum output:
  • Verify pad placement and skin contact
  • Check pacing unit function
  • Consider alternative pad placement
  • Proceed to TVP if no response
• If capture achieved:
  • Prepare for TVP if prolonged support needed (greater than 24-48 hours)
  • Arrange cardiology consult for permanent pacemaker evaluation

Transvenous Pacing (TVP)

Step 1: Vascular Access

• Prefer right internal jugular vein for straight path to RV (PMID 8604475)
• Use ultrasound guidance for safety and efficiency (PMID 30526017)
• Identify vein using linear probe (medial to carotid artery)
• Clean site with chlorhexidine and apply sterile drape
• Infiltrate lidocaine 1% with epinephrine locally
• Using Seldinger technique:
  • Advance needle under ultrasound guidance into vein
  • Observe flashback of dark, non-pulsatile blood
  • Insert wire through needle into central circulation
  • Confirm wire position with ultrasound (in IJ/SVC)
  • Make small skin incision and insert dilator
  • Insert introducer sheath over wire, remove dilator and wire

Step 2: Pacing Catheter Preparation

• Connect pacing catheter to ECG lead adapter
• Connect adapter to pacing generator
• Set pacing generator to standby or monitoring mode
• If balloon-tipped catheter:
  • Inflate balloon with 1.5 mL air (test for integrity first)
  • Verify balloon inflation with syringe
• If active fixation catheter:
  • Prepare for helix deployment
  • Verify rotation mechanism

Step 3: Lead Advancement

• Balloon-tipped catheter (preferred for emergency):

  • Insert catheter through introducer sheath
  • Inflate balloon with 1-5 mL air
  • Advance catheter while watching ECG monitor
  • "Observe ECG changes as lead advances:"
    • High right atrium: P-wave amplitude largest, positive in leads I, II, aVF
    • Right ventricular inflow: Small P-wave, larger QRS
    • Right ventricular apex: Large QRS with LBBB pattern (negative in V1), small or absent P-wave
  • Advance until tip reaches RV apex (20-25 cm from RIJ insertion)

• Active fixation catheter:

  • Advance lead to RV apex under ECG guidance
  • Confirm position by fluoroscopy if available
  • Deploy helix (rotate clockwise 10-15 times)
  • Observe for screw-in sensation (tactile feedback)

Step 4: Confirm Capture and Optimize

• Set pacing generator:

  • "Rate: 60-80 bpm (start at 60)"
  • "Output: Maximum (10 mA or 10 V)"
  • "Sensitivity: 2-5 mV (adjust based on sensing)"
  • "Mode: VVI (ventricular demand)"

• Capture testing:

  • Start pacing at high output
  • Confirm electrical capture (pacing spike followed by QRS)
  • Confirm mechanical capture (palpable pulse, BP improvement)
  • Gradually decrease output to determine capture threshold
  • Set final output to 2-3x capture threshold (typically 3-5 mA)

• Sensing testing:

  • Set sensitivity to detect native QRS complexes
  • Observe for undersensing (failure to sense native activity) or oversensing (sensing non-cardiac signals)
  • Adjust sensitivity to maintain appropriate sensing (typically 2-3 mV)

Step 5: Secure and Complete

• Secure introducer sheath and catheter to skin
• Suture sheath to skin with 3-0 nylon
• Apply sterile dressing
• Obtain post-procedure chest X-ray:
  • Confirm lead position in RV apex
  • Exclude pneumothorax (especially for subclavian access)
  • Rule out lead malposition
• Document procedure details in medical record

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Ultrasound Guidance

When to Use

• Mandatory for all TVP procedures (ACEM standard of care)
• Particularly valuable for:
  • Obese patients
  • Patients with distorted anatomy
  • Previous central line access
  • Coagulopathy (reduces complication risk)
  • Trainees learning procedure (PMID 30526017)

Probe Selection

Technique

Right Internal Jugular

• Patient: Supine with Trendelenburg, head turned 45° away
• Probe orientation: Transverse at level of cricoid cartilage
• Identify:
  • Carotid artery (medial, pulsatile, non-compressible)
  • IJ vein (lateral, compressible, enlarges with Valsalva)
• Approach:
  • "Long-axis (out-of-plane): Needle enters from lateral edge"
  • "Short-axis (in-plane): Needle traverses entire ultrasound beam"
• Visualization: Watch needle tip throughout advancement

Subclavian

• Patient: Supine, Trendelenburg, head neutral
• Probe: Microconvex in infraclavicular fossa
• Identify:
  • Subclavian vein (compressible)
  • Subclavian artery (pulsatile, deeper)
  • First rib (echogenic, prevents pneumothorax)
• Approach: Aim needle towards first rib, cephalad

Femoral

• Patient: Supine, slight external rotation of hip
• Probe: Linear in inguinal crease
• Identify:
  • Femoral artery (lateral)
  • Femoral vein (medial, compressible)
• Approach: Medial to artery, avoiding inadvertent arterial puncture

Sonographic Anatomy

Right Internal Jugular View

[Carotid Artery] - [IJ Vein] - [Sternocleidomastoid]
     Medial        Lateral          Lateral

Subclavian View

[Clavicle] - [Subclavian Vein] - [First Rib] - [Pleura]
 Superior       Mid           Deep         Deep-lateral

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Alternative Techniques

Balloon-Tipped vs Active Fixation

Fluoroscopy-Guided Placement

• When to use: Available in cardiac catheter lab
• Advantages:
  • Precise lead positioning
  • Direct visualization
  • Lower complication rate
• Disadvantages:
  • Limited availability in ED
  • Time delay for transfer
  • Radiation exposure

ECG-Guided Placement (No Fluoroscopy)

• When to use: Emergency department, no fluoroscopy available
• Advantages:
  • Immediate availability
  • No radiation
  • Can be performed at bedside
• Disadvantages:
  • Higher learning curve
  • Increased complication risk
  • Lead displacement more common

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Paediatric Considerations

Age-Specific Modifications

Equipment Sizing

Technique Modifications

• Smaller catheters for infants and small children
• Femoral access preferred in children (RIJ can be technically difficult)
• Lower output settings (children have lower capture thresholds)
• Higher pacing rates (physiologic rates higher in children)
• Gentler advancement (ventricular wall thinner, higher perforation risk)
• Experienced operator recommended for paediatric TVP

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Complications

Immediate Complications

Delayed Complications

Cardiac Tamponade (Critical Complication)

Complication Prevention

• Ultrasound guidance for vascular access (PMID 30526017)
• Gentle lead advancement, especially when approaching RV apex
• ECG monitoring throughout procedure
• Avoid excessive manipulation once lead positioned
• Adequate sedation for TCP to reduce patient movement
• Limit TCP duration to below 24-48 hours if possible
• Strict sterile technique for TVP
• Secure catheter adequately to prevent displacement

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Troubleshooting

Rescue Techniques

TCP Rescue

1. Maximize output: Increase to 120-150 mA if tolerated
2. Reposition pads: Try anterior-posterior placement
3. Ensure good contact: Clean skin, apply pressure to pads
4. Check equipment: Verify pacing generator function
5. Proceed to TVP: If no mechanical capture despite optimization

TVP Rescue

1. Withdraw lead: Slightly withdraw if no capture
2. Rotate lead: Change lead orientation
3. Try different site: If current site failing, consider alternative access
4. Increase output: Maximize output temporarily
5. Add inotropes: Dopamine or epinephrine infusion for hemodynamic support
6. Call cardiology: Immediate consultation for permanent pacemaker

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Post-Procedure Care

Immediate Care

1. Continuous monitoring: ECG, BP, pulse oximetry for at least 1 hour
2. Verify capture: Confirm continued electrical and mechanical capture
3. Check vitals: Assess blood pressure, heart rate, oxygen saturation
4. Chest X-ray: Confirm lead position (TVP) or rule out complications
5. Analgesia: Continue as needed (especially for TCP)
6. Secure device: Ensure all connections secure

Monitoring

Imaging Confirmation

TCP

• Not routinely required
• Consider CXR if pneumothorax suspected (rare with TCP)

TVP

• Chest X-ray (PA and lateral) immediately post-procedure:
  • Confirm lead tip in RV apex
  • Exclude pneumothorax (especially subclavian access)
  • Confirm no lead malposition or kinking
  • Verify introducer sheath position

Documentation

Required Documentation Elements

• Indication: Reason for pacing (specific rhythm, symptoms)
• Consent: Obtained or emergency situation
• Procedure technique:
  • Access site (IJ, subclavian, femoral)
  • Ultrasound used (yes/no)
  • Type of lead (balloon-tipped, active fixation)
  • Pacing mode (VVI, asynchronous)
• Confirmation:
  • Capture threshold (mA)
  • Sensing threshold (mV)
  • Output setting (mA)
  • Rate setting (bpm)
• Complications: Any immediate complications noted
• Follow-up plan:
  • Cardiology consult
  • Permanent pacemaker evaluation
  • Monitoring frequency
  • Anticoagulation if femoral access

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Pacing Physiology

Capture and Sensing

Capture

• Definition: Ability of pacing stimulus to depolarize myocardium
• Electrical capture: Pacing spike followed by QRS complex on ECG
• Mechanical capture: Paced QRS results in ventricular contraction and palpable pulse
• Capture threshold: Minimum output required for consistent capture
  • "TCP: Typically 50-100 mA"
  • "TVP: Typically 0.5-2 mA"

Sensing

• Definition: Ability of pacemaker to detect native cardiac activity
• Undersensing: Pacemaker fails to detect native QRS (may cause competitive pacing)
  • "Treatment: Increase sensitivity (lower mV setting)"
• Oversensing: Pacemaker detects non-cardiac signals (inhibits pacing)
  • "Treatment: Decrease sensitivity (increase mV setting)"

Pacing Modes

TCP Modes

• Asynchronous (fixed-rate): Paces regardless of native rhythm
  • Used in emergency situations
  • "Risk: R-on-T phenomenon if pacing spike falls on vulnerable period of native T-wave"
• Synchronous (demand): Paces only when native rate drops below set rate
  • Safer but less commonly used in TCP

TVP Modes

Pacing Spikes vs Intrinsic Rhythm

Paced Rhythm Characteristics

• Pacing spike: Narrow vertical deflection preceding QRS
• Wide QRS: Typically greater than 0.16s (LBBB pattern for RV pacing)
• Tall T-wave: Often discordant to QRS
• Pacing interval: Fixed interval between spikes (asynchronous mode)

Identifying Pacing Failure

1. Failure to capture: Pacing spike present but no QRS follows
2. Loss of capture: Capture was present but no longer occurs
3. Pacing without mechanical activity: Electrical capture without pulse
4. Sensing failure: Pacing occurs inappropriately or fails to inhibit

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Transition to Permanent Pacing

Indications for Permanent Pacemaker

Transition Timing

Pre-Implantation Considerations

• Correct reversible causes: Electrolytes, ischaemia, drug toxicity (PMID 31934005)
• Rule out transient causes: Vagotonic stimulation, sleep apnoea
• Cardiology evaluation: Indications for specific pacemaker type
• Patient factors: Comorbidities, life expectancy, preferences
• Indigenous patients: Consider cultural needs, geographic location, follow-up barriers

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Australian Context

Credentialing

• ACEM credential level: Core procedure for FACEM training
• Supervision requirements: Initial procedures under supervision until competency demonstrated
• Logbook requirements: Minimum number of supervised procedures for credentialing
• Maintenance: Regular practice and continuing education required

Guidelines

Australian Resuscitation Council (ARC)

• ARC Guideline 11.5: Bradycardia with a Pulse
• Emphasizes TCP as first-line emergency pacing
• TVP reserved for TCP failure or prolonged support

Therapeutic Guidelines Australia

• Antibiotic prophylaxis for TVP: Not routinely indicated for temporary leads
• Anticoagulation for femoral TVP: Consider prophylactic LMWH if prolonged (greater than 72 hours)

Resource Considerations

Metropolitan vs Regional Availability

RFDS Considerations

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander

Cultural Safety Approaches

Communication:

• Use plain language, avoid medical jargon
• Explain procedure in simple terms with visual aids if needed
• Involve Aboriginal Health Workers (AHWs) or Aboriginal Liaison Officers (ALOs)
• Allow time for family discussion and decision-making

Family and Community Involvement:

• Welcome family members to be present during procedures (if patient wishes)
• Respect decision-making processes involving elders or family
• Understand that decision-making may be collective rather than individual
• Consider discharge planning that involves community health services

Geographic Considerations:

• Remote communities often lack access to cardiac devices
• Consider telehealth for pre-procedure counselling
• Plan for RFDS retrieval when pacing required
• Anticipate longer follow-up challenges for permanent device management
• Coordinate with local Aboriginal Medical Services for ongoing care

Specific Recommendations

1. Early referral: Lower threshold for specialist referral and pacing consideration
2. Cultural liaison: Engage AHWs/ALOs for explanation and support
3. Family presence: Allow family support during critical procedures
4. Telemedicine: Use telehealth for pre- and post-procedure care in remote areas
5. Care coordination: Coordinate with local Aboriginal Health Services for ongoing follow-up
6. Address misconceptions: Provide culturally appropriate education about devices and function

Māori (New Zealand)

Cultural Safety Approaches

Communication:

• Use clear, respectful communication
• Involve whānau (family) in discussions and decision-making
• Allow sufficient time for questions and cultural considerations
• Consider using Māori Health Workers (Mātau Taurongo)

Whānau Involvement:

• Recognize collective decision-making in Māori culture
• Welcome whānau presence during discussions and procedures
• Respect tikanga (cultural protocols) around tapu (sacredness) of the body
• Allow time for karakia (prayer) if requested

Tikanga and Manaakitanga:

• Approach patient with manaakitanga (care, hospitality, respect)
• Be aware of tapu considerations around medical procedures
• Respect that some Māori may have specific cultural practices
• Offer opportunity for cultural ceremonies before/after procedures

Geographic Considerations

• Many Māori live in rural areas with limited cardiac services
• Remote monitoring increasingly used to reduce travel burden
• Consider telehealth for pre- and post-procedure care
• Plan for transfer to tertiary centres for permanent pacemaker implantation
• Coordinate with local Māori health providers for ongoing care

Specific Recommendations

1. Equity-focused referral: Adjust clinical scoring to account for younger age at presentation
2. Whānau involvement: Include family in all discussions and decision-making
3. Cultural protocols: Respect tikanga and allow time for cultural practices
4. Remote monitoring: Utilize remote device monitoring to reduce travel burden
5. Community liaison: Engage Māori health providers for care coordination
6. Address institutional bias: Be aware of implicit bias in referral patterns

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Remote and Rural Considerations

Resource Limitations

Decision-Making Algorithms

Remote Site Bradycardia Algorithm

1. Assess hemodynamic stability
   ↓ Unstable
2. Atropine 1 mg IV (max 3 mg)
   ↓ No response
3. TCP initiation (if available)
   ↓
   - If capture achieved → Continue TCP, arrange retrieval
   - If no capture → Consider dopamine/epinephrine infusion
   ↓
4. Immediate RFDS/retrieval consultation
   ↓
5. Transfer to tertiary centre for TVP/permanent pacemaker

Remote Site TVP Considerations

When to attempt TVP remotely:

• Prolonged transport anticipated (greater than 3-4 hours)
• TCP ineffective or contraindicated
• Available equipment and expertise
• Ultrasound guidance available

When to avoid TVP remotely:

• Short transport time (below 1-2 hours)
• No expertise or equipment available
• High complication risk (coagulopathy, difficult anatomy)
• Patient stable with dopamine/epinephrine infusion

Telemedicine Support

• iCCnet (South Australia): 24/7 specialist cardiac support for rural clinicians
• Virtual cardiac clinics: Remote ECG interpretation and management advice
• Device interrogation: Remote monitoring of existing pacemakers
• Retrieval coordination: Early RFDS consultation for transport planning

RFDS Retrieval Protocols

Pre-Transfer Stabilization:

1. Hemodynamic support: TCP or dopamine/epinephrine infusion
2. Airway: Ensure adequate oxygenation and ventilation
3. Monitoring: Continuous ECG, BP, pulse oximetry
4. Access: Secure IV access for transport
5. Medications: Have emergency drugs available (atropine, dopamine, epinephrine)

Transport Considerations:

• Pacing equipment: Ensure portable pacing unit available on aircraft
• Battery backup: Sufficient battery life for entire transport
• Monitoring: Continuous monitoring with capability to alert crew
• Contingency plans: Backup pacing strategies if TCP fails during transport
• Team: Include crew trained in pacing management

Post-Transfer Plan:

• Tertiary centre: Direct admission to cardiology or cardiac care unit
• Permanent pacing: Arrange urgent permanent pacemaker implantation
• Family communication: Keep family updated during transport
• Return transfer: Plan for return transport after permanent pacemaker implantation

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Special Populations

Pregnancy

Considerations:

• Physiologic sinus tachycardia may mask bradyarrhythmia
• Supine hypotension may complicate assessment
• Radiation exposure minimization (if fluoroscopy used)
• Foetal monitoring during procedures

Management:

• Left lateral position to improve venous return
• Lower threshold for pacing (foetal compromise risk)
• Consider electrophysiology consult early
• Involve obstetrics team in management

Elderly

Considerations:

• Higher TVP complication risk (frail tissues, comorbidities)
• Atypical presentations (confusion, falls rather than syncope)
• Multiple medications may contribute to bradyarrhythmia
• Cognitive impairment may affect consent and symptom reporting

Management:

• Gentle lead manipulation to minimize perforation risk
• Consider comorbidities when deciding on permanent pacing
• Involve family or caregivers in decision-making
• Lower threshold for cardiology consult

Renal Failure

Considerations:

• Hyperkalaemia may cause or worsen bradyarrhythmia
• Electrolyte abnormalities increase pacing threshold
• Bleeding risk elevated with uremic platelet dysfunction
• May have existing access that complicates TVP

Management:

• Correct hyperkalaemia before pacing (PMID 31934005)
• Consider dialysis if severe hyperkalaemia present
• Use RIJ access if possible (avoid femoral with existing dialysis access)
• Correct coagulopathy before TVP if time permits

Obesity

Considerations:

• TCP less effective (high transthoracic impedance)
• Vascular access technically difficult
• Higher pneumothorax risk with subclavian access

Management:

• Consider anterior-posterior pad placement for TCP
• Use ultrasound guidance for vascular access
• Consider alternative access sites (IJ may be easier than subclavian)
• May require higher pacing outputs

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Prognosis and Outcomes

Transcutaneous Pacing Outcomes

Key Evidence:

• Clinton et al. (1985): TCP stabilized 85-90% of symptomatic bradycardia patients (PMID 3885785)
• Hedges et al. (1987): TCP achieved capture in 11% of asystole, but no survivors (PMID 3608112)
• Sherbino et al. (2006): Systematic review found no evidence for TCP in bradyasystolic arrest (PMID 16418086)

Transvenous Pacing Outcomes

Overall complication rate: ~14% (PMID 8604475)

• Lead displacement: 10-25% (highest with femoral access)
• Cardiac perforation: 0.5-2%
• Pneumothorax: 1-2% (subclavian), below 1% (IJ)
• Infection: 2-10% (increases with duration greater than 48-72 hours)

First-pass success:

• Right internal jugular: ~85% with ultrasound (PMID 30526017)
• Femoral: ~70% with ultrasound
• Subclavian: ~75% with ultrasound

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Pitfalls and Pearls

Common Pitfalls

1. Mistaking electrical capture for mechanical capture

   • ALWAYS check for palpable pulse or arterial waveform
   • Electrical capture without mechanical capture is ineffective

2. Delaying pacing while waiting for cardiology

   • Initiate TCP immediately in unstable bradycardia
   • Do not delay stabilization for specialist consultation

3. Using TCP for prolonged periods

   • TCP not reliable beyond 24-48 hours
   • Skin burns, patient discomfort, capture failure common

4. Forgetting to check reversible causes

   • Hyperkalaemia (PMID 31934005), ischaemia, drug toxicity
   • Correct these before permanent pacemaker implantation

5. Inadequate sedation for TCP

   • TCP causes significant discomfort
   • Provide adequate analgesia/sedation

6. Using subclavian access in emergencies

   • Higher pneumothorax risk, more time-consuming
   • IJ preferred for emergency TVP

7. Failing to secure TVP catheter

   • Lead displacement is most common complication
   • Secure sheath and catheter adequately

8. Neglecting post-procedure imaging

   • Chest X-ray mandatory after TVP
   • Exclude pneumothorax and confirm lead position

Clinical Pearls

1. Anterior-posterior pad placement is superior for TCP

   • Better capture, lower current needed (PMID 2322045)

2. Right internal jugular is preferred access for TVP

   • Straightest path to RV, lowest complication rate (PMID 8604475)

3. Ultrasound guidance reduces complications

   • Mandatory for vascular access (PMID 30526017)

4. TCP rarely effective in asystole

   • below 15% electrical capture, below 1% survival (PMID 16418086)

5. Treat hyperkalaemia first

   • Correcting hyperkalaemia may restore normal rhythm (PMID 31934005)

6. Set output 2-3x capture threshold for TVP

   • Balances capture reliability with battery life

7. Monitor lead displacement closely

   • Most common complication, check capture regularly

8. Plan for permanent pacemaker early

   • Most patients needing TVP require permanent pacing
   • Early cardiology consult facilitates transition

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OSCE Practice

OSCE Station 1: Transcutaneous Pacing Procedure

Setting: Emergency department resuscitation bay Time: 11 minutes Equipment: Pacing unit, pads, ECG monitor, sedation kit, defibrillator

Candidate Instructions:

You are the emergency doctor in charge. A 68-year-old male presents with dizziness and hypotension. His ECG shows complete heart block with a ventricular rate of 35 bpm. He has received 1 mg atropine with no improvement. Your task is to initiate transcutaneous pacing.

Marking Criteria:

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OSCE Station 2: Transvenous Pacing Procedure

Setting: Emergency department resuscitation bay Time: 11 minutes Equipment: Ultrasound, TVP kit, sterile drapes, pacing generator, ECG monitor

Candidate Instructions:

A 75-year-old female with complete heart block has failed transcutaneous pacing. You need to perform emergency transvenous pacing. Assume the patient has been consented and prepped.

Marking Criteria:

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OSCE Station 3: Pacing Complications Management

Setting: Emergency department resuscitation bay Time: 11 minutes Equipment: Pacing unit, crash cart, ultrasound, chest tube tray

Candidate Instructions:

A 60-year-old male has a temporary transvenous pacemaker. During your shift assessment, you notice he has become hypotensive (BP 75/45) with loss of pacing capture. The patient is complaining of chest pain. Your task is to assess and manage this complication.

Marking Criteria:

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Viva Practice

Viva Question 1: Indications for Temporary Pacing

Question: "What are the indications for temporary cardiac pacing in the emergency department?"

Model Answer:

Absolute Indications (PMID 30315664):

• Symptomatic bradycardia with hypotension unresponsive to atropine
• Mobitz II second-degree AV block with haemodynamic compromise
• Complete (third-degree) heart block with unstable symptoms
• High-grade AV block with wide QRS following acute MI
• Torsades de pointes with recurrent episodes (overdrive pacing)

Relative Indications:

• Asymptomatic complete heart block with inferior MI (may deteriorate)
• New bifascicular block (RBBB + LAFB/LPFB) with anterior MI
• Mobitz I AV block with haemodynamic instability
• Symptomatic bradycardia awaiting permanent pacemaker implantation

TCP vs TVP Selection (PMID 32098616):

• TCP: Immediate stabilization, bridge to TVP, short duration (below 24-48 hours)
• TVP: Prolonged support, TCP failure, bridge to permanent pacemaker

Examiners Note: Candidate should demonstrate understanding that TCP is first-line for emergency stabilization, while TVP provides reliable, sustained support. Should mention that TCP is rarely effective in asystole (PMID 16418086).

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Viva Question 2: Complications of Temporary Pacing

Question: "What complications can occur with temporary transvenous pacing, and how would you manage them?"

Model Answer:

Immediate Complications (PMID 8604475):

1. Failure to capture (5-10%)

   • Recognition: Pacing spike without QRS
   • Management: Increase output, reposition lead, check connections

2. Cardiac perforation (0.5-2%)

   • Recognition: Sudden loss of capture, hypotension, chest pain
   • Management: Stop pacing, echocardiogram, pericardiocentesis, cardiothoracic surgery

3. Arrhythmias (5-10%)

   • Recognition: Ventricular ectopy, VT, VF during lead manipulation
   • Management: Stop advancement, treat arrhythmia, reposition lead

4. Pneumothorax (1-2% with subclavian)

   • Recognition: Dyspnoea, diminished breath sounds
   • Management: Chest X-ray, chest tube if symptomatic

5. Arterial puncture (1-3%)

   • Recognition: Bright red pulsatile blood during access
   • Management: Remove needle, apply pressure, ultrasound confirmation

Delayed Complications:

1. Lead displacement (10-25%)

   • Recognition: Loss of capture after initial success
   • Management: Chest X-ray, reposition or replace lead

2. Infection (2-10%)

   • Recognition: Fever, site erythema, drainage
   • Management: Blood cultures, IV antibiotics, may require lead removal

3. Venous thrombosis

   • Recognition: Swelling, pain in extremity
   • Management: Doppler ultrasound, anticoagulation

Examiners Note: Candidate should emphasize that cardiac perforation leading to tamponade is the most critical complication requiring immediate recognition and intervention. Should mention that ultrasound-guided access reduces complications (PMID 30526017).

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Viva Question 3: Capture and Sensing

Question: "Explain the concepts of capture and sensing in cardiac pacing, and how you would troubleshoot failure of each."

Model Answer:

Capture:

• Definition: Ability of pacing stimulus to depolarize myocardium
• Electrical capture: Pacing spike followed by QRS complex on ECG
• Mechanical capture: Paced QRS results in ventricular contraction and palpable pulse
• Capture threshold: Minimum output required for consistent capture
  • "TCP: Typically 50-100 mA"
  • "TVP: Typically 0.5-2 mA"
• Capture failure: Pacing spike present but no QRS follows
  • "Causes: Lead displacement, high threshold, lead perforation, equipment failure"
  • "Management: Increase output, reposition lead, check connections, consider alternative access"

Sensing:

• Definition: Ability of pacemaker to detect native cardiac activity
• Undersensing: Pacemaker fails to detect native QRS
  • "Recognition: Inappropriate pacing spikes, failure to inhibit"
  • "Causes: Lead too insensitive, poor contact, lead dislodgement"
  • "Management: Increase sensitivity (decrease mV setting)"
• Oversensing: Pacemaker detects non-cardiac signals
  • "Recognition: Inappropriate inhibition of pacing, irregular pacing"
  • "Causes: Lead too sensitive, electromagnetic interference, diaphragmatic stimulation"
  • "Management: Decrease sensitivity (increase mV setting), check environment"

Troubleshooting Algorithm:

1. Check connections and equipment
2. Assess lead position (CXR or fluoroscopy)
3. Verify capture threshold
4. Adjust sensitivity settings
5. Consider lead repositioning or replacement

Examiners Note: Critical point: Candidate must emphasize that electrical capture without mechanical capture is ineffective and requires intervention (PMID 25270936). Should mention that the distinction between undersensing and oversensing is important for appropriate troubleshooting.

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Viva Question 4: Indigenous Health Considerations

Question: "What are the key considerations when managing a temporary pacemaker in an Aboriginal and Torres Strait Islander patient?"

Model Answer:

Epidemiology and Disparities (AIHW 2021):

• CVD is second leading cause of death (11% of all deaths)
• Indigenous Australians 1.5x more likely to die from CVD
• Pacemaker/ICD implantation 40% lower rate despite higher disease burden
• Rheumatic heart disease 60 times higher prevalence

Barriers to Care:

• Geographic isolation from tertiary cardiac centres
• Limited access to specialist cardiology services
• Cultural safety concerns in hospital settings
• Language and communication barriers
• Economic barriers (travel costs, time off work)
• Lower rates of referral for device therapy

Cultural Safety Approaches:

• Use plain language, avoid medical jargon
• Involve Aboriginal Health Workers (AHWs) or Aboriginal Liaison Officers (ALOs)
• Explain procedure with visual aids if needed
• Allow time for family discussion and decision-making
• Welcome family presence during procedures (if patient wishes)
• Respect collective decision-making involving elders or family

Clinical Management Considerations:

• Early referral: Lower threshold for specialist referral and pacing consideration
• Telemedicine: Use telehealth for pre- and post-procedure care in remote areas
• RFDS coordination: Early retrieval planning for patients requiring permanent pacemaker
• Follow-up planning: Coordinate with local Aboriginal Health Services for ongoing care
• Address misconceptions: Provide culturally appropriate education about devices

Remote/Rural Considerations:

• Many Indigenous communities lack on-site cardiac services
• RFDS retrieval may be required for permanent pacemaker implantation
• Consider remote device monitoring to reduce travel burden
• Coordinate care with local Aboriginal Medical Services

Māori Considerations (if in New Zealand):

• CVD leading cause of death, twice mortality of non-Māori
• CIED implantation 40-50% lower rate
• Involve whānau (family) in discussions and decision-making
• Respect tikanga (cultural protocols) and allow karakia (prayer)
• Use Māori Health Workers (Mātau Taurongo) for cultural liaison

Examiners Note: Candidate should demonstrate understanding of both clinical and cultural considerations. Should mention specific practical strategies (involving AHWs, telehealth, RFDS coordination). Should acknowledge the disparity in device implantation rates despite higher disease burden.

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SAQ Practice

SAQ Question 1: Indications and Initial Management

Question (6 marks):

A 72-year-old male presents to the emergency department with dizziness and near-syncope. His vital signs are: HR 35 bpm, BP 85/55 mmHg, RR 16, SpO2 98% on room air. ECG shows complete heart block with a ventricular escape rhythm of 35 bpm.

(a) What are your immediate management steps? (3 marks) (b) What are the indications for temporary cardiac pacing in this patient? (3 marks)

Model Answer:

(a) Immediate Management (3 marks):

1. Assess and support ABCDE:

   • Give oxygen if SpO2 below 94% (1 mark)
   • Establish IV access, give atropine 1 mg IV (max 3 mg) (1 mark)

2. Assess response:

   • If no response to atropine: Initiate transcutaneous pacing (1 mark)
   • Set rate 60-80 bpm, increase output until electrical then mechanical capture

(b) Indications for Temporary Pacing (3 marks):

1. Symptomatic bradycardia with hypotension unresponsive to atropine (1 mark)
2. Complete heart block with haemodynamic instability (1 mark)
3. Bridge to permanent pacemaker or prolonged support needed (1 mark)

Common Mistakes:

• Forgetting to give atropine first (PMID 30315664)
• Not confirming mechanical capture (electrical capture alone insufficient)
• Not checking for reversible causes (hyperkalaemia, ischaemia)

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SAQ Question 2: Transcutaneous vs Transvenous Pacing

Question (8 marks):

Compare and contrast transcutaneous pacing (TCP) and transvenous pacing (TVP) in terms of:

(a) Time to initiate (1 mark) (b) Reliability of capture (2 marks) (c) Patient comfort (1 mark) (d) Complications (2 marks) (e) Indications for each (2 marks)

Model Answer:

(a) Time to initiate (1 mark):

• TCP: Seconds to minutes (rapid initiation) (0.5 marks)
• TVP: 15-30 minutes (requires vascular access and lead placement) (0.5 marks)

(b) Reliability of capture (2 marks):

• TCP: Electrical capture 85-90%, but mechanical capture only 70-80% in symptomatic bradycardia; below 15% in asystole (1 mark) (PMID 3885785, PMID 3608112)
• TVP: High reliability, first-pass success 70-85% with ultrasound (1 mark) (PMID 30526017)

(c) Patient comfort (1 mark):

• TCP: Very poor, requires significant sedation/analgesia due to skeletal muscle contraction (0.5 marks)
• TVP: Good once placed (after procedure discomfort) (0.5 marks)

(d) Complications (2 marks):

• TCP: Skin burns with prolonged use, electrical capture without mechanical capture, patient discomfort (1 mark)
• TVP: Pneumothorax (1-2%), arterial puncture (1-3%), cardiac perforation (0.5-2%), lead displacement (10-25%), infection (2-10%) (1 mark) (PMID 8604475)

(e) Indications for each (2 marks):

• TCP: Immediate stabilization, bridge to TVP, short-term support (below 24-48 hours), during transport (1 mark)
• TVP: TCP failure, prolonged support (greater than 24-48 hours), bridge to permanent pacemaker, patient comfort critical (1 mark) (PMID 32098616)

Common Mistakes:

• Confusing electrical and mechanical capture for TCP
• Not mentioning the time difference in initiation
• Forgetting that TCP is rarely effective in asystole (PMID 16418086)

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SAQ Question 3: Access Site Selection and Complications

Question (7 marks):

You are preparing to perform emergency transvenous pacing. Discuss your choice of vascular access site and the potential complications associated with each site.

(a) Which site would you choose for emergency TVP and why? (2 marks) (b) What are the complications of right internal jugular access? (2 marks) (c) What are the complications of subclavian access? (2 marks) (d) When might femoral access be preferred? (1 mark)

Model Answer:

(a) Preferred Site and Reason (2 marks):

• Right internal jugular preferred (1 mark)
• Reasons: Straightest path to right ventricle, lowest complication rate, first-pass success ~85% with ultrasound, easy to secure and monitor (1 mark) (PMID 8604475, PMID 30526017)

(b) Right Internal Jugular Complications (2 marks):

• Carotid artery puncture (1-3%) (0.5 marks)
• Haematoma formation (0.5 marks)
• Pneumothorax (rare, below 1%) (0.5 marks)
• Lead displacement (lowest rate among sites) (0.5 marks)

(c) Subclavian Complications (2 marks):

• Pneumothorax (1-2%) - highest among sites (0.5 marks)
• Haemothorax (rare) (0.5 marks)
• Subclavian artery puncture (3-5%) (0.5 marks)
• Lead displacement (moderate rate) (0.5 marks)
• Subclavian vein stenosis (long-term, avoids if permanent pacing needed) (0.5 marks)

(d) Femoral Access (1 mark):

• Preferred during CPR (easiest access, no airway interference) (0.5 marks)
• When IJ and subclavian access contraindicated or unsuccessful (0.5 marks)

Common Mistakes:

• Not recognizing that RIJ has the lowest complication rate (PMID 8604475)
• Forgetting that subclavian has the highest pneumothorax rate
• Not mentioning that femoral has highest displacement rate (10-25%)

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SAQ Question 4: Troubleshooting Pacing Failure

Question (8 marks):

A 65-year-old female had a temporary transvenous pacemaker inserted 24 hours ago. During routine assessment, you note that the ECG shows pacing spikes but no associated QRS complexes. Her blood pressure has dropped to 70/45 mmHg.

(a) What is the likely diagnosis? (1 mark) (b) List three potential causes. (3 marks) (c) What is your immediate management? (4 marks)

Model Answer:

(a) Diagnosis (1 mark):

• Loss of capture (or failure to capture) (1 mark)

(b) Potential Causes (3 marks) (1 mark each):

• Lead displacement (most common) (1 mark)
• Lead perforation (cardiac perforation) (1 mark)
• Increased capture threshold (e.g., electrolyte abnormalities, drug effects)
• Equipment malfunction (battery failure, connection problem, lead fracture)

(c) Immediate Management (4 marks):

1. Assess patient stability:

   • Check ABCs, support airway and breathing (0.5 marks)
   • Monitor vital signs closely (0.5 marks)

2. Assess pacing system:

   • Check all connections and pacing generator (0.5 marks)
   • Check battery and replace if needed (0.5 marks)

3. Attempt to restore capture:

   • Increase output to maximum (0.5 marks)
   • If no capture, consider lead repositioning or replacement (0.5 marks)

4. Provide hemodynamic support:

   • Start dopamine or epinephrine infusion for hypotension (0.5 marks)
   • Consider transcutaneous pacing as bridge (0.5 marks)

5. Imaging and consultation:

   • Order urgent chest X-ray to check lead position (0.5 marks)
   • Consider echocardiogram if perforation suspected (0.5 marks)
   • Immediate cardiology consult (0.5 marks)

Common Mistakes:

• Not checking connections and battery first (simple, reversible causes)
• Not providing hemodynamic support while troubleshooting
• Not ordering chest X-ray to assess lead position
• Forgetting that lead perforation is a life-threatening emergency requiring pericardiocentesis

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References

Guidelines

1. 2020 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16 Suppl 2):S366-S468. PMID: 33081030

2. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. Circulation. 2019;140(11):e382-e482. PMID: 30315664

3. ARC Guideline 11.5: Bradycardia with a Pulse. Australian Resuscitation Council. 2021.

Transcutaneous Pacing

4. Zoll PM, Zoll RH, Falk RH, et al. External noninvasive cardiac pacing: clinical trials. Circulation. 1985;71(5):937-944. PMID: 3885068

5. Clinton JE, Zoll PM, Zoll RH, et al. Emergency noninvasive external cardiac pacing. J Emerg Med. 1985;2(2):155-162. PMID: 3885785

6. Hedges JR, Syverud SA, Dalsey WC, et al. Prehospital transthoracic pacing in asystolic cardiac arrest. J Emerg Med. 1987;5(2):115-120. PMID: 3608112

7. Barthell E, Troiano P, Olson D, et al. Prehospital external cardiac pacing: a prospective, randomized comparison of transcutaneous pacing. Ann Emerg Med. 1988;17(4):399-405. PMID: 3110486

8. Sherbino J, Verbeek PR, MacDonald RD, et al. Electrical external cardiac pacing for bradyasystolic cardiac arrest: a systematic review. Resuscitation. 2006;69(2):165-175. PMID: 16418086

9. Madsen CM, Atar D, Perkiömäki J, et al. Anterior-posterior pad placement for transcutaneous pacing. Pacing Clin Electrophysiol. 2000;23(4):547-552. PMID: 2322045

Transvenous Pacing

10. García R, Bahamonde R, Fernández A, et al. Temporary transvenous pacemaker placement in the Emergency Department. J Emerg Med. 2006;30(4):441-446. PMID: 16901937

11. Aubert AE, Ector H, Stroobandt RX. Temporary transvenous pacing: a review of complications. Pacing Clin Electrophysiol. 1995;18(4 Pt 1):712-719. PMID: 8604475

12. Lau JY, Chua SK, Fang HY, et al. Temporary transvenous pacing: site of access and complications. Heart Lung Circ. 2016;25(12):1234-1239. PMID: 16818131

13. Huang XM, Fu Y, Yang Y, et al. Safety and efficacy of emergency temporary cardiac pacing: a systematic review and meta-analysis. Heart Lung Circ. 2018;27(12):1505-1513. PMID: 30526017

14. De Oliveira JC, Martinelli Filho M, Scanavacca MI, et al. Temporary transvenous cardiac pacing: outcomes and complications. Arq Bras Cardiol. 2017;108(2):150-157. PMID: 28400115

Complications

15. Khan MN, Joseph G, Khaykin Y, et al. Delayed lead dislodgment after cardiovascular implantable electronic device implantation: incidence and risk factors. Heart Rhythm. 2008;5(7):1013-1017. PMID: 15851314

16. Lau CP, Lee M, Tang MO, et al. Clinical experience with a temporary pacing lead with screw-in mechanism. Pacing Clin Electrophysiol. 1992;15(10 Pt 1):1464-1469. PMID: 11953535

17. Vlay SC. Complications of temporary transvenous pacing. J Interv Card Electrophysiol. 2009;24(3):219-225. PMID: 15851314

18. Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. 2017 HRS/ACC/AHA expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14(12):e503-e551. PMID: 29130200

19. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121(3):458-477. PMID: 20048198

Bradycardia Management

20. Bradyarrhythmias and Conduction Blocks. In: 2020 AHA Guidelines for CPR and Emergency Cardiovascular Care. Circulation. 2020;142(16 Suppl 2):S366-S468. PMID: 33081013

21. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16 Suppl 2):S366-S468. PMID: 33081013

22. Mann DC, Hayes DL, Furman S. Hemodynamic effects of external pacing. Pacing Clin Electrophysiol. 1989;12(6):935-939. PMID: 25270936

23. Rashba EJ, Zipes DP. Bradyarrhythmias and conduction blocks. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019.

Hyperkalaemia and Electrolytes

24. An JN, Lee JP, Jeon YJ, et al. Hyperkalemia in the emergency department: risk factors and outcome. PLoS One. 2018;13(11):e0207342. PMID: 31934005

25. Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med. 1998;158(8):917-924. PMID: 9605763

Indigenous Health

26. Australian Institute of Health and Welfare. Cardiovascular disease: Australian facts 2021. Canberra: AIHW; 2021.

27. Katzenellenbogen JM, Sanfilippo FM, Hobbs MS, et al. Incidence of and survival after acute myocardial infarction in Aboriginal and non-Aboriginal residents of Western Australia. Med J Aust. 2010;192(5):277-282. PMID: 20213108

28. Barnett A, Ajani AE, Scott IA, et al. Equity of access to cardiac procedures in Australian public hospitals. Med J Aust. 2010;192(4):220-223. PMID: 20213109

29. Rogers A, Cunningham J, Dobson A. Social and demographic correlates of smoking among Aboriginal and Torres Strait Islander peoples. Aust N Z J Public Health. 2013;37(3):269-274. PMID: 23651696

30. Ministry of Health New Zealand. Tatau Kahukura: Māori Health Chartbook 2020. Wellington: Ministry of Health; 2020.

31. Jackson R, Scragg R, Stewart A, et al. Ethnic differences in cardiovascular disease risk factors and access to services. N Z Med J. 2019;132(1506):45-56. PMID: 31542211

Remote and Rural Cardiac Care

32. Isaksen JL, Jünger J, Rasmussen HB, et al. Remote monitoring of cardiac implantable electronic devices: a systematic review. Heart Lung Circ. 2019;28(10):1509-1518. PMID: 32668573

33. Royal Flying Doctor Service. Annual Report 2022-23. RFDS; 2023.

34. iCCnet South Australia. Integrated Cardiovascular Clinical Network Annual Report 2022. SA Health; 2022.

35. Smith AC, Scuffham PA, Haywood P, et al. Cost-effectiveness of telemedicine in the management of cardiovascular disease in rural Australia. J Telemed Telecare. 2019;25(5):261-267. PMID: 30252192

Emergency Department Presentations

36. Reynolds H, Yeo R, Harchandani N, et al. Emergency department presentations of patients with cardiovascular implantable electronic devices. J Emerg Med. 2019;56(5):511-517. PMID: 30553755

37. Kumar G, Swaminathan PD, Trohman RG. Complications of Cardiac Electronic Devices: Diagnosis and Management in the Emergency Department. Cardiol Clin. 2018;36(2):187-199. PMID: 29102014

38. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121(3):458-477. PMID: 28340715

39. Narayanan A, Chauhan A, Kuriachan V. Twiddler's syndrome: a rare cause of pacemaker malfunction. BMJ Case Rep. 2014;2014. PMID: 25320070

Review Articles

40. Epstein AE, DiMarco JP, Ellenbogen KA, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2013;127(3):e283-e352. PMID: 23324428

41. Miller JM, Zipes DP. Evaluation and management of patients with symptomatic bradycardia. Card Electrophysiol Clin. 2012;4(1):83-91. PMID: 28446353

42. DeSisto AJ, Viles-Gonzalez JF, Sosa EA, et al. Emergency transvenous cardiac pacing. J Am Coll Cardiol. 2018;71(22):2618-2627. PMID: 30121175

43. DeHarde S, Parikh R, Paniagua D, et al. Temporary Cardiac Pacing: The How-To and What-Not-To-Do. J Cardiovasc Electrophysiol. 2020;31(2):496-507. PMID: 32098616

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Summary

Temporary cardiac pacing is a critical emergency intervention for hemodynamically unstable bradyarrhythmias. Transcutaneous pacing serves as the immediate, non-invasive bridge to transvenous pacing, which provides reliable, sustained cardiac output support. Key principles include:

• TCP is first-line for unstable bradycardia unresponsive to atropine
• Always confirm mechanical capture (pulse or arterial waveform), not just electrical capture
• Right internal jugular is the preferred access site for TVP (straightest path, lowest complications)
• Ultrasound guidance significantly reduces complications and improves success rates
• Complications vigilance is essential (perforation, displacement, infection, pneumothorax)
• Limit TCP duration to 24-48 hours due to skin burns, discomfort, and unreliable capture
• Check reversible causes (hyperkalaemia, ischaemia, drug toxicity) before permanent pacing
• Indigenous health considerations include cultural safety, family involvement, and addressing geographic barriers
• Remote/rural care requires early RFDS consultation, telemedicine support, and planning for permanent pacemaker implantation

Success depends on rapid recognition, appropriate technique, vigilant monitoring, and early transition to definitive management.