Using a Transcutaneous (External) Pacemaker

Skill 15-6

Using a Transcutaneous (External) Pacemaker

Temporary cardiac pacing is used to electrically stimulate the myocardium to correct life-threatening cardiac dysrhythmias such as bradycardia (Burns & Delgado, 2019). A temporary pacemaker consists of an external, battery-powered pulse generator and a lead or electrode system to electrically stimulate heartbeat. Most manual defibrillators and some AEDs are equipped to perform transcutaneous pacing (Hinkle et al., 2022). Transcutaneous pacing can temporarily supply an electrical current in the heart when electrical conduction is abnormal. This device works by sending an electrical impulse from the pulse generator to the patient's heart by way of two large-surface electrodes, which are placed on the front and back of the patient's chest. This stimulates the contraction of cardiac muscle fibers through electrical stimulation (depolarization) of the myocardium. Transcutaneous pacing is quick and effective but is usually used as short-term therapy until the situation resolves or transvenous or permanent pacing can be initiated (Burns & Delgado, 2019; Morton & Fontaine, 2018).

Transcutaneous pacing can cause significant discomfort (burning sensation and involuntary muscle contraction) (Hinkle et al., 2022). The patient should be informed, adequately sedated, and provided analgesia whenever possible (Burns & Delgado, 2019; Morton & Fontaine, 2018, p. 312; Stout, 2017).

Delegation Considerations

The use of a transcutaneous pacemaker is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, this procedure may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Transcutaneous noninvasive pacemaker
Transcutaneous pacing electrodes and cables
ECG electrodes and cables
Cardiac monitor
Medication for analgesia and/or sedation, as prescribed

Assessment

Review the patient's health record and care plan for information about the patient's need for pacing and as a prescribed intervention. Transcutaneous pacing is generally an emergency measure. Assess the patient's initial cardiac rhythm, including a rhythm strip and 12-lead ECG. Monitor heart rate, respiratory status, level of consciousness, and skin color. If the patient is pulseless, initiate CPR.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired cardiac output
Altered tissue perfusion
Injury Risk

Outcome Identification and Planning

The expected outcomes to achieve when using an external transcutaneous pacemaker are that it is applied correctly without adverse effect; the patient regains and/or maintains signs of adequate circulation, including the capture of at least the minimal set heart rate; and the patient does not experience injury.

Implementation

Action	Rationale
1. Verify the prescribed intervention for a transcutaneous pacemaker in the patient's health record.	Verifying the prescribed intervention ensures that the correct intervention is administered to the right patient.
2. Gather all equipment.	Assembling equipment provides for an organized approach to the task.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the transmission of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Verifying the patient's identity validates that the correct procedure is being done on the correct patient.
5. If the patient is responsive, explain the procedure to them. Explain that it involves some discomfort and that you will administer medication to keep them comfortable and help them to relax. Administer analgesia and sedation, as prescribed, if it is not an emergency situation.	Most alert patients cannot tolerate the uncomfortable sensations produced by the high energy levels needed to pace externally (Zagkli et al., 2020). If responsive, the patient will most likely be sedated and given analgesia (Burns & Delgado, 2019; Hinkle et al., 2022; Morton & Fontaine, 2018; Stout, 2017).
6. Close the curtains around the bed and close the door to the room, if possible. Obtain vital signs.	This provides for patient privacy. Vital signs provide a baseline for assessing pacing effectiveness.
7. If necessary, prepare the skin for electrode placement (AACN, 2018). If an area is excessively hairy, clip the hair (AACN, 2018; Oster, n.d.), or shave the hair with a single-use razor (Campbell et al., 2017), according to facility policy. Clean excess oil or other substances from the skin with a skin cleanser and water. Use a gauze pad to vigorously rub and dry the skin.	Shaving may cause microabrasions on the skin, possibly resulting in portals of entry for microorganisms. Oils and excess hair interfere with electrode contact and function. Rubbing with gauze abrades and dries the skin. Proper skin preparation is essential to reduce artifacts in and increase quality of the pacing (AACN, 2018; Campbell et al., 2017; Garcia, 2015; Oster, n.d.).
8. Attach the cardiac monitoring electrodes to the patient in the lead I, II, and III positions (refer to Skill 15-5). Do this even if the patient is already on telemetry monitoring. If you select the lead II position, adjust the left leg (LL) electrode placement to accommodate the anterior pacing electrode and the patient's anatomy.	Cardiac monitoring electrodes must be placed in addition to the pacing electrodes in order for the pacemaker to read the patient's cardiac rhythm while the pacing electrodes deliver the energy needed to pace the heart (Stout, 2017). Connecting the telemetry electrodes to the pacemaker is required.
9. Attach the patient monitoring electrodes to the ECG cable and into the ECG input connection on the front of the pacing generator. Set the selector switch to the “Monitor on” position.	These actions ensure that the equipment is functioning properly.
10. Note the ECG waveform on the monitor. Adjust the R-wave beeper volume to a suitable level and activate the alarm by pressing the “Alarm on” button. Set the alarm for 10 to 20 beats lower and 20 to 30 beats higher than the patient's target pacing rate.	These actions ensure that the equipment is functioning properly. Alarms alert the nurse to potential concerns regarding the patient's status.
11. Press the “Start/Stop” button for a printout of the waveform.	A printout provides objective data.
12. Apply the two pacing electrodes, starting with the posterior electrode. Pull the protective strip from the posterior electrode (marked “Back”) and apply the electrode on the left side of the thoracic spinal column, just below the scapula (Figure 1).	This placement ensures that the electrical stimulus will travel only a short distance to the heart.
13. Apply the anterior pacing electrode (marked “Front”), which has two protective strips—one covering the gelled area and one covering the outer rim. Expose the gelled area and apply it to the skin in the anterior position, to the left of the precordium in the V₂ to the V₅ position (see Figure 1). Move this electrode around to get the best waveform. Then expose the electrode's outer rim and firmly press it to the skin.	This placement ensures that the electrical stimulus will travel only a short distance to the heart.
14. Prepare to pace the heart. After making sure the energy output in milliamperes (mA) is on 0, connect the electrode cable to the monitor output cable.	This sets the pacing threshold.
15. Check the waveform, looking for a tall QRS complex in lead II.
16. Check the selector switch to “Pacer on.” Select synchronous (demand) or asynchronous (fixed-rate or nondemand) mode, as prescribed. Tell the patient they may feel a thumping or twitching sensation. Reassure the patient you will provide analgesic medication if the discomfort is intolerable.	Asynchronous pacing delivers a stimulus at a set (fixed) rate regardless of the occurrence of spontaneous myocardial depolarizations (the patient's own underlying heart rate). Synchronous pacing delivers a stimulus only when the heart's intrinsic pacemaker fails to function at a predetermined rate (if the patient's own heart rate drops below the demand rate set on the pacemaker). Analgesia and/or sedation may be administered, as prescribed and indicated, for discomfort associated with pacing (Burns & Delgado, 2019; Hinkle et al., 2022; Morton & Fontaine, 2018; Stout, 2017).
17. Set the pacing rate dial to a target pacing rate of 60 to 70 beats/min. Look for pacer artifact or spikes, which will appear as you increase the rate.	Setting the pacing rate dial higher than the intrinsic rhythm ensures adequate cardiac output.
18. Set the pacing current output (in mA), if not automatically done by the pacemaker. For patients with bradycardia, start with the minimal setting and slowly increase the amount of energy delivered to the heart by adjusting the “Output” mA dial. Do this until electrical capture is achieved: you will see a pacer spike followed by a widened QRS complex and a tall broad T wave that resembles a premature ventricular contraction.	Setting the pacing current output ensures adequate cardiac output.
19. Increase output by 2 mA or 10% to ensure capture. Do not go higher (unless prescribed or indicated) because of the increased risk of discomfort to the patient. Print a strip and place it in the patient's health record.	Increasing the output ensures consistent capture. With full capture, the patient's heart rate should be the same as the pacemaker rate shown on the machine. The usual pacing threshold is between 40 and 80 mA. Thresholds may vary due to recent cardiothoracic surgery, pericardial effusions, cardiac tamponade, acidosis, and hypoxia. These conditions may require higher thresholds. Printing a strip documents the patient's paced rhythm.
20. Assess for effectiveness of pacing and mechanical capture: observe for a pacemaker spike with subsequent capture; assess heart rate and rhythm (using the right carotid, brachial, or femoral artery), assess blood pressure, and assess for signs of improved cardiac output (increased blood pressure, improved level of consciousness, improved body temperature).	Both electrical and mechanical capture must occur to benefit the patient (Stout, 2017). Transcutaneous pacing spikes are usually very large and may distort the QRS complex in electrocardiography (Burns & Delgado, 2019). The presence of a pulse with every pacing spike confirms ventricular capture (Burns & Delgado, 2019). Use of the patient's right side for pulse assessment avoids inaccuracy related to strong contractions from the pacemaker.
21. Secure the pacing leads and cable to the patient's body.	This prevents accidental displacement of the electrode, resulting in failure to pace or sense.
22. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene and proper disposal of equipment reduce the transmission of microorganisms.
23. Continue to monitor the patient's heart rate and rhythm to assess ventricular response to pacing. Assess the patient's vital signs, skin color, level of consciousness, and peripheral pulses. Take blood pressure in both arms.	Assessment helps determine the effectiveness of the paced rhythm. If the blood pressure reading is significantly higher in one arm, use that arm for measurements.
24. Continue to assess the patient's pain and administer analgesia/sedation, as prescribed, to ease the discomfort of chest wall muscle contractions.	Analgesia and sedation promote patient comfort.
25. Perform a 12-lead ECG and additional ECGs daily or with clinical changes.	ECG monitoring provides a baseline for further evaluation.
26. Continually monitor the ECG readings, noting capture, sensing, rate, intrinsic beats, and competition of paced and intrinsic rhythms. If the pacemaker is sensing correctly, the sense indicator on the pulse generator should flash with each beat.	Continuous monitoring helps evaluate the patient's condition and determine the effectiveness of therapy.

Evaluation

The expected outcomes have been met when the external transcutaneous pacemaker has been applied correctly without adverse effect; the patient has regained and/or maintained signs of adequate circulation, including the capture of at least the minimal set heart rate; and the patient has not experienced injury.

Documentation

Guidelines

Document the reason for pacemaker use, time that pacing began, electrode locations, pacemaker settings, the patient's response to the procedure and to temporary pacing, complications, and nursing actions taken. Document the patient's pain intensity rating, analgesia or sedation administered, and the patient's response. If possible, obtain a rhythm strip before, during, and after pacemaker placement; anytime the pacemaker settings are changed; and whenever the patient receives treatment because of a complication due to the pacemaker.

Sample Documentation

1/2/25

1218 Baseline rhythm strip obtained, sinus bradycardia at 43 beats/min; see flow sheet. External temporary pacemaker placed by Dr. Goodman. Cardiac monitoring electrodes placed in the lead I, II, and III positions. Pacer set in synchronous mode at rate of 80 beats/min; pacing current output 72 mA. Patient with strong femoral pulses; see flow sheet for vital signs. Patient reports chest discomfort of 4/10. Medicated with morphine 2 mg IV. Pacer alarms set at 50 and 90 beats/min.

—R. Robinson, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Failure to pace: This happens when the pacemaker either does not fire or fires too often. The pulse generator may not be working properly, or it may not be conducting the impulse to the patient. If the pacing or sensing indicator flashes, check the connections to the cable and the position/contact of the pacing electrodes on the patient. The cable may have come loose, or the electrode may not be making contact. If the pulse generator is turned on, but the indicators still are not flashing, change the battery. If that does not help, use a different pulse generator. Check the settings if the pacemaker is firing too rapidly. If they are correct, or if altering them (according to your facility's policy or the prescribed intervention) does not help, change the pulse generator.
Failure to capture: Pacemaker spikes are seen, but the heart is not responding. The most common reason is failure to increase the current sufficiently. It may also be caused by changes in the pacing threshold from ischemia, an electrolyte imbalance (high or low potassium or magnesium levels), acidosis, an adverse reaction to a medication, or fibrosis. If the patient's condition has changed, notify the health care provider, and ask for new settings. Carefully check all connections, making sure they are placed properly and securely. Increase the milliamperes slowly (according to facility policy or the prescribed intervention).
Failure to sense intrinsic beats: This could cause ventricular tachycardia or ventricular fibrillation if the pacemaker fires on the vulnerable T wave. This could be caused by the pacemaker sensing an external stimulus as a QRS complex, which could lead to asystole, or by the pacemaker not being sufficiently sensitive, which means it could fire anywhere within the cardiac cycle. If the pacing is undersensing, turn the sensitivity dial toward lower millivolt value. If it is oversensing, reduce the sensitivity; the value in millivolts should be larger to make the pacer less sensitive (Morton & Fontaine, 2018). If the pacemaker is not functioning correctly, change the battery or the pulse generator.

Special Considerations

Transcutaneous pacing spikes are usually very large, often distorting the QRS complex in electrocardiography (Burns & Delgado, 2019). The presence of a pulse with every pacing spike confirms ventricular capture (Burns & Delgado, 2019).
Do not leave patients unattended during noninvasive pacing. It is safe to touch the patient and perform procedures during pacing (e.g., CPR). Gloves should be worn. Do not touch the conductive surface of the electrodes.
Check the skin where the electrodes are placed for skin burns or tissue damage (Hinkle et al., 2022). Reposition, as needed.

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Skill 15-6