Transcutaneous Pacing in the Field
Objective: Recognize when TCP is the move, confirm mechanical capture with a pulse, and sedate only if protocol allows.
Why This Is Hard
The strip is a third-degree block and the patient is crashing. Crews push atropine twice because pacing “looks mean.” AHA 2025 adult bradycardia: do not delay pacing in unstable high-grade block.
- Defib pads in a recommended position (anterior-lateral or anterior-posterior per your device).
- Set a rate per protocol, then increase milliamps until you see a QRS after every spike — then feel a pulse.
- Spikes without a femoral/carotid pulse is not capture. Turn up current or reposition; treat as PEA if pulseless.
Field Rules (Education)
- Indication theme: symptomatic/unstable bradycardia — hypotension, AMS, shock, ischemic pain — especially Mobitz II / complete block.
- Atropine may be tried per protocol but is less reliable below the AV node. Do not wait through three unsuccessful atropine cycles while they are dying.
- Capture: electrical (paced QRS) plus mechanical (pulse). Both.
- Sedation/analgesia if they are awake and protocol allows. Pacing hurts. This site does not publish the drug.
Field Pitfalls
- Calling spikes on the screen “pacing” with no pulse.
- Delaying TCP for atropine in a crashing complete block.
- Pediatric pads on an adult because they were closer.
Practice
60-second drill
Partner: 34 bpm, complete block, BP 68, moaning. First device action and how you will prove capture.
Related: Symptomatic bradycardia, AV blocks.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- AHA 2025 Part 9: Adult ALS — unstable bradycardia: pacing; atropine less reliable in infranodal block
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.