Version 5.0
The Johns Hopkins Hospital
Policy Number
CC642
Nursing Practice and Organization Manual Vol II: Clinical
Critical Care
Effective Date
12/04/2013
Approval Date
N/A
Subject
Page
Pacemaker, Transcutaneous, Management of the Patient with
Supercedes
1 of 4
07/01/2010
Keywords: pacemaker, transcutaneous, Zoll, TCP,
Table of Contents
Page Number
I.
OBJECTIVES
II.
INDICATIONS FOR USE
III.
DEFINITIONS
IV.
RESPONSIBILITY
V.
PROCEDURE
VI.
REPORTABLE CONDITIONS
VII. DOCUMENTATION
VIII. SUPPORTIVE INFORMATION
Appendix A: Troubleshooting Transcutaneous Pacemaker
1
1
1
1
2
3
4
4
Click Here
I. OBJECTIVES
The objective of this protocol is to provide guidance for the nursing staff care for a patient requiring temporary transcutaneous
pacing.
II. INDICATIONS FOR USE
Initiate this protocol for patients requiring a temporary transcutaneous pacing for symptomatic bradycardia, or bradycardia due
to autonomic instability, drug toxicity and/or anesthesia, temporary bridge in presence of permanent or temporary pacemaker
failure, Type II second degree or third degree AV block. Prepare for temporary transvenous or emergent permanent pacemaker.
III. DEFINITIONS
Asynchronous Pacing Mode
The pacemaker releases a pacing stimulus at the
programmed rate regardless of the heart’s intrinsic
activity.
Demand Pacing Mode
The pacemaker withholds its pacing stimulus after sensing
a spontaneous depolarization. Also thought of as the
pacer inhibiting when it senses intrinsic activity or that is
synchronizes with intrinsic activity of the heart.
Mode
Can be either demand or asynchronous.
Output
Level of energy, expressed in milliamperes (mA).
Rate
The rate at which pacing stimuli is emitted from pulse
generator.
Sensitivity
The degree to which a pacemaker is responsive to levels
of electrical activity in the heart.
Stimulation Threshold
The least amount of electrical energy (measured in mA)
required to elicit a ventricular contraction.
IV. RESPONSIBILITY
A.
Authorized Prescriber
1. Write an order to initiate and maintain transcutaneous pacemaker including the following:
a. Output (mA)
Version 5.0
The Johns Hopkins Hospital
Policy Number
CC642
Nursing Practice and Organization Manual Vol II: Clinical
Critical Care
Effective Date
12/04/2013
Approval Date
N/A
Subject
Pacemaker, Transcutaneous, Management of the Patient with
B.
Page
Supercedes
2 of 4
07/01/2010
b. Rate
2. Order continuous cardiac monitoring.
3. Order analgesics or sedation as needed
Registered Nurses (RN)
1. Who have demonstrated competency will attach and maintain external pacemaker to patient.
V. PROCEDURE
A.
B.
Assessment:
1. Assess the patient’s intrinsic cardiac rhythm (if not continuously pacing) and hemodynamic response to determine
need for external pacing.
2. Assess for other factors that may cause or exacerbate bradycardia including current medications (e.g. digoxin,
calcium channel blockers, beta blockers, amiodarone) and lab values.
3. Within one hour of assuming care of the patient who has intermittent or continuous pacing, every 2 hours and prn.
a. SETTINGS: verify the pacemaker settings per the authorized prescriber order:
i.
Rate
ii. Pacer output (mA)
b. Assess for pacing effectiveness via continuous cardiac monitoring: note failure to sense, failure to pace or
failure to capture.
c. Assess hemodynamic response to pacing including:
i.
Vital signs (It is recommended that cuff BP should be obtained in the right arm due to elevation of
pressures in the left arm with external pacing).
ii. Level of consciousness
iii. Urine output
d. Check electrode sites for adherence and skin integrity. If adherence is a problem, clip hairs. DO NOT SHAVE,
as it increases the risk of burns.
e. Assess for evidence of pain and need for analgesics or sedation.
f.
Assure alarms on external pacer are set appropriately and remain on at all times.
4. Assess every 4 hours and prn the following
a. Underlying rhythm if visible. In order to view underlying rhythm when continuously pacing, utilize the 4:1
button, (not all makes/models of transcutaneous pacers have this function). By pushing and holding the 4:1
button, pacing stimuli is temporarily withheld so that every 4th beat is a paced beat. Pacer setting remain
unchanged.
b. Percent of time paced (complete, intermittent, non-pacing).
c. Pacemaker settings as compared to orders (output (mA), rate).
d. Carotid, femoral or peripheral pulses.
5. Asynchronous pacing should only be performed in emergency situations when there are no other alternatives. (Zoll
M and Zoll R Series biphasic AEDs/Defibrillator default to demand pacing/ asynchronous pacing can be initiated by
pressing the “Asynch Pacing On/Off key”.
Interventions
1. For the Zoll M Series biphasic AED/Defibrillator, attach the Zoll 3-lead ECG monitoring lead wires to patient.
The Zoll M Series will not pace without lead wires applied to patient.
2. For the Zoll R Series biphasix AED/Defibrillator the 3 lead ECG monitoring lead system is built into the OneStep
CPR Complete pads.
a. Pediatrics patients: must attach the Zoll 3-lead ECG monitoring lead wires to the patient.
3. Placement of pacing electrode pads:
a. Check the expiration date on the pacing electrode pad package. Discard if they are expired or the package has
been opened.
b. Remove any medication patches from the chest (particularly nitroglycerin patches and paste).
Version 5.0
The Johns Hopkins Hospital
Policy Number
CC642
Nursing Practice and Organization Manual Vol II: Clinical
Critical Care
Effective Date
12/04/2013
Approval Date
N/A
Subject
Pacemaker, Transcutaneous, Management of the Patient with
c.
C.
Supercedes
3 of 4
07/01/2010
Prepare the patient’s skin by washing with soap and water, rinse and dry well. Clip excess hair-DO NOT
SHAVE. Using a towel, use a circular motion to abrade the application site. DO NOT use alcohol or benzoin
on the skin as these may increase the risk of burns.
d. Avoid placement of pads over bony structures, external wires and open skin areas.
e. If the pacing electrodes have been previously placed frontally for defibrillation or cardioversion, they may
be left in place for the first attempt to pace. If immediately unsuccessful, use the following positioning that is
preferred for pacing.
i.
Apply the “front/apex/lateral” pacing pad at the left, fourth intercostal space, midclavicular line. Adjust
position of pad below and lateral to breast tissue to ensure optimal adherence. Roll the electrode onto the
patient's chest. Evacuate any air pockets that are trapped between the skin and the electrode. Press down
on the entire surface to assure uniform adhesion. Avoid touching the stimulation side of the electrode pad.
ii. Using the same application method described above, apply the back pad between spine and left scapula
at the level of the heart with the monitoring portion pointing down. The posterior pad should be directly
behind the anterior pad in a “sandwiched” position.
iii. In emergency situations such as VT or Vfib switch from pacer mode to defibrillator mode. Defibrillation
can be done with the pacing pads in the front and back position.
4. Consider sedation (IV analgesics or sedation) for pacing discomfort.
5. Take the following steps to provide fixed-rate (asynchronous) or demand pacing:
a. Follow manufacturer’s operating instructions for turning on the defibrillator, monitor and pacing unit.
b. Select Lead II and maximize R-wave size. The Zoll R Series will have a P before the Lead selected to indicate
that the 3 lead ECG monitoring is from the OneStep CPR Complete pads.
c. Confirm the suspected arrhythmia on the ECG.
d. Select demand or asynchronous mode, rate and output (mA) per physician order. (Slowly in increase the energy
level (mA) until consistent capture occurs at the prescribed rate).
e. Assess electrical capture by observing the ECG display. Capture is usually evidenced by a pacer spike followed
by a wide QRS complex and tall, broad T waves.
f.
Assess mechanical or ventricular capture by evaluating cardiac output. Each QRS should be accompanied by
a palpable pulse. Use right carotid, femoral or brachial pulse to avoid confusion between the jerking muscle
contractions caused by the pacer and true pulse.
g. As soon as there is capture, adjust the current ouput to 10% above the lowest effective level (stimulation
threshold).
h. Change electrode every 24 hours and prn.
i.
Obtain 12 lead ECG every day and prn.
j.
Keep external pacemaker/defibrillator plugged in at all times except during transport (battery limit is about 2
hours).
k. If the Zoll is used as the primary monitor, set alarm limits on the external pacemaker/defibrillator based on the
patient’s condition.
Trouble Shooting: See Appendix Troubleshooting Zoll M and R series for pacing.
VI. REPORTABLE CONDITIONS
A.
B.
C.
D.
Page
Failure to capture or sense by the pacemaker.
New onset dysrrhythmia.
Signs of decreased cardiac output related to pacemaker failure.
Signs of external pacing complications including:
1. Patient pain and discomfort
2. Skin irritation and/or redness
3. Diaphragmatic stimulation
4. Chest wall muscle stimulation
Version 5.0
The Johns Hopkins Hospital
Policy Number
CC642
Nursing Practice and Organization Manual Vol II: Clinical
Critical Care
Effective Date
12/04/2013
Approval Date
N/A
Subject
Pacemaker, Transcutaneous, Management of the Patient with
Page
Supercedes
4 of 4
07/01/2010
VII. DOCUMENTATION
A.
Document the following on the appropriate paper or electronic nursing forms.
1. Intrinsic heart rate and rhythm
2. Vital signs
3. Signs of improved perfusion
4. Pacemaker settings
5. Stimulation threshold
6. Carotid, femoral, or peripheral pulses
VIII. SUPPORTIVE INFORMATION
See Also:
Mosby, Nursing skills on line
The Johns Hopkins Hospital, Nursing Practice and Organization Manual Vol II
•
CC644 Management of Patient with a Transvenous/Epicardial Pacemaker
Reference:
1.
2.
3.
4.
5.
6.
7.
American Heart Association. (2000). Textbook of Advanced Cardiac Life Support, Author.
Cardiotronics. Stimulation electrode therapy using self adhesive electrodes pads: Pacing and defibrillation.
Paschall, F.E., & McErlean, E.S. (2001). Temporary transcutaneous (external) pacing/ In D. J. Lynn-McHale & K.K.
Carlson (Eds.), AACN Procedure manual for critical care (4th Ed., pp 271-277). Philadelphia, PA: Elsevier.
Teplits, L. (1991). Transcutaneous pacemakers. Journal of Cardiovscular Nursing, 5(3), 44-56.
Waggoner, P.C. (1991). Transcutaneous cardiac pacing. AACN Clinical Issues, 2(1), 118-125.
Zoll PD 1200, Pacemaker/Defibrillator Operator’s Guide. ZMI Corportation, Waburn, MA.
Eileen M. Kelly., (2005). Temporary Transcutaneous (External) Pacing. In D. J. Lynn-McHale Wiegand & K. K. Carlson
(Eds). AACN procedure manual for critical care (5th ed.) 333-339. Philadelphia: W. B. Saunders.
Sponsor:
ICU Nursing SOC
Developers:
Cardiology Care Unit