Emergency Transvenous Pacing

See Also

Unstable Bradycardia

Indications

Alternative to Transcutaneous Pacing
Unstable Bradycardia (e.g. third degree AV Block)
Prolonged transport time with higher likelihood of rhythm decompensation
Myocardial Infarction with new Arrhythmia (LBBB, RBBB, Type II second degree AV Block, Third Degree AV Block)
1. High risk of fatal Bradycardia (up to 43%)
2. However, first priority is reperfusion!

Advantages
Contrast with Transcutaneous Pacing

Requires only one tenth of the delivered energy (milliamps) as Transcutaneous Pacing
Does not require nearly the same level of sedation and analgesia as Transcutaneous Pacing
Does not generate the significant tracing artifacts seen with Transcutaneous Pacing

Technique

Preferred Central Line sites (most direct, least tortuous courses)
1. Right internal Jugular Vein (preferred)
2. Left subclavian vein
Place Catheter 6 French sheath (in Pacemaker kit)
1. Use 6 French instead of 9 French standard Cordis catheter
2. The larger, 9 French leaks blood and fails to allow adequate Pacemaker wire control
Attach the plastic, accordion sheath
1. Connect the sheeth hub to the catheter
2. Wire threaded through the sterile sheath and into the catheter
3. Test wire balloon by inserting 1.5 cc air prior to insertion (then deflate)
Attach the pacer
1. Connector cable attached to the Pacemaker wire and to the Pacemaker generator
2. Non-sterile assistant attaches catheter pins to appropriate terminal on generator (+ to +, - to -)
Thread the wire
1. Deflate balloon
2. Pass wire via sterile sheath into 6 French catheter
3. Wire inserted to the second mark (20 cm)
Advance Wire
1. Turn on Pacemaker generator once tip has cleared introducer sheath
  1. Rate: 60-80 bpm
  2. Sensitivity: Asynchronous, lowest possible
  3. Output: 5 mA
    1. Some recommend setting to maximal ouput (20 mA) to start
    2. Decrease output once capture occurs (see below)
2. Reinflate balloon
  1. Inflate balloon with 1.5 cc air and turn stop-cock
  2. Balloon reinflated to allow floating of wire into the right atrium and right ventricle
3. Advance the wire to the third mark (30 cm)
4. EKG Monitor (not the EKG machine or alligator clip)
  1. Observe for electrical and mechanical capture
  2. Electrical tracing will show a Pacemaker spike followed by Wide QRS (LBBB appearance)
  3. Heart Rate will increase from Bradycardia to pacer rate at capture
    1. Palpate pulse or auscultate heart sounds
    2. Oxygen Saturation waveform
    3. Bedside Ultrasound of heart
5. Troubleshooting problems passing through the tricuspid valve
  1. Short Stature patient
    1. Withdraw the introducer by small increments and reattempt
  2. Tricuspid regurgitation pushes balloon backwards into right atrium
    1. Consider threading without balloon inflated
  3. Consider alternative access site other than internal Jugular Vein
    1. Subclavian line
    2. Femoral line
Deflate balloon
1. Open stopcock and allow balloon to deflate spontaneously (syringe fills with air)
2. If capture lost, reinflate balloon and advance again
Secure catheter and pacer
1. Extend sheath to cover pacing catheter and tighten the associated valve
Consider confirming lead placement with Bedside Ultrasound
1. Use Subxiphoid Echocardiogram View
Adjust Pacemaker generator
1. Decrease pacer output until capture is lost (typically 0.3 mA or less)
  1. Increase again until capture occurs and to approximately 2.5 times lowest capture threshold

Safety

Safe and effective (95% sucess rate) when performed in the emergency department for Symptomatic Bradycardia
1. Birkhahn (2004) Ann Emerg Med 43(4): 469-74 +PMID: 15039689 [PubMed]
2. Piela (2016) Am J Emerg Med 34(8): 1411-4 +PMID: 27133534 [PubMed]

References

Bessman in Roberts (2014) Roberts and Hedges Emergency Procedures, Elsevier, Philadelphia, p. 277-97
Kwon and Warrington (2016) Crit Dec Emerg Med 30(9):10-11
Orman and Bellezzo in Herbert (2016) EM:Rap 16(4): 8-9
Sacchetti in Herbert (2017) EM:Rap 17(5): 1-2