Friday, January 20, 2017

Transcutaneous Pacing

 Patient admitted with elevated BP and shortness of breath.  Hx of diabetes, renal failure, dialysis, PVD, MI

Initial rhythm






VS: 97.4 38-26.  204/89. Monitor, oxygen, IV started.  0.5 mg of atropine given.  No change in rhythm.




Initiate transcutaneous pacing.  Rate 60 ppm




Increased milliamps to 50.  No mechanical capture

Increased milliamps to 60. No mechanical capture

MD into evaluate patient.  Pacing paused to evaluate.  Rhythm 1st degree block.










Demand pacing.  Underlying rhythm 1st degree block with periods of arrest.





She had good capture at 70 mAs.  She had a lot of musculoskeletal contractions. It was difficult to even feel a femoral pulse.  A doppler was used and it found her heart rate to be in the 40s.  At this point, we increased the mAs up to 90.  The doppler rate was now 60 ppm


80 mAs.










90 mAs.  Doppler rate 60 ppm.   SpO2 rate correlates too.



100% paced with good mechanical capture by doppler. Patient sent to cath lab for transvenous pacemaker insertion.








4 comments:

  1. I love me a good case of transcutaneous pacing, however I do not see any signs of electrical capture on these tracings. They all show pseudo-capture cause by pacing artifact and you can see the underlying QRS complexes and T-waves maching through. Do you have any of the 90 mA strips? Thanks!

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  2. Oh, and btw, the sixth and ninth strips are duplicates; perhaps that's why the 90 mA strip is missing.

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  3. Thanks for you comments Vince DiGiulio. I added a few more strips to add some clarity. The pacing complexes did not "look" right to me. (No negative QRS with positive ST). So that prompted me to check the pulse with the doppler. We did begin to get some mechanical capture with the increase in the mAs. So, we were getting some contractions. I would be glad to send you these strips if you would like to add them to you blog and make further analysis. Thanks for your comments.

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  4. That sounds great Mike! I would love the chance to pick apart the tracings a bit and add some markups of what I think is going on. You can reach me at VinceD87@gmail.com at your leisure, and thank you for the prompt reply and being so open to discussing this case. One of the big reasons I find TCP so interesting precisely because it's challenging and often leads to debates regarding what's actually happening with the patient.

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