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Lesson

Transcutaneous Pacing in the Field

10 min Cardiac & ECG Skip to quiz

Objective: Use transcutaneous pacing (TCP) for unstable bradycardia, especially high-grade block. A paced QRS is not enough. You need a pulse. Sedate only if your protocol allows it.

Why this matters

If the rhythm is third-degree block and the patient is unstable, set up transcutaneous pacing (TCP). TCP means pads that pace from the skin. Do not give atropine again only because pacing looks harsh. Do not delay pacing in unstable high-grade block. A QRS after each spike is not enough. You need a pulse with those beats.

Key points
  • Place defibrillator pads in the position your device recommends, anterolateral or anterior-posterior.
  • Set the rate per protocol. Then increase the output until you see a QRS after every spike, and then feel a pulse.
  • Spikes without a femoral or carotid pulse are not capture. Turn the output up or move the pads. If they are pulseless, treat PEA (pulseless electrical activity).

Clinical sequence

  1. If this is unstable bradycardia, give atropine per protocol while you set up pacing. Do not wait for a perfect 12-lead if the patient is unstable.
  2. Put the pads anterior-posterior or anterolateral, as you were trained. Turn the pacer on. Set the rate, then the output, until you have mechanical capture: a pulse with each paced beat.
  3. Sedate or give analgesia if they are awake and protocol allows it. A QRS on the screen is not a pulse in the neck.
  4. If there is no mechanical capture and they are pulseless, start CPR. Use a vasopressor only if your protocol allows it. Transport. Do not stand and watch the electrical spikes.

Teaching points

  • When to pace: symptomatic or unstable bradycardia — hypotension, altered mental status, shock, or ischemic pain — especially Mobitz II or complete block.
  • Atropine may be tried per protocol, but it is less reliable when the block is below the atrioventricular (AV) node. Do not wait through repeated failed atropine doses while the patient is unstable.
  • You need both kinds of capture. Electrical capture is a paced QRS after the spike. Mechanical capture is a pulse. Electrical capture is not enough.
  • Sedation or analgesia if they are awake and protocol allows it. Pacing hurts. This site does not publish the drug.

Common errors

  • Calling spikes on the screen “pacing” when there is no pulse.
  • Delaying TCP for more atropine in an unstable complete block.
  • Using pediatric pads on an adult because they were closer.

Practice

One-minute check

Partner: rate 34, complete block, BP 68, and the patient is moaning. Say the 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.

Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.

Check Your Understanding

Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.

1. Electrical capture without a pulse means:
2. Unstable complete heart block — what about pacing?
3. Pacing an awake patient:
4. Atropine in Mobitz II / complete block is:
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