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INTRODUCTION

Transcutaneous cardiac pacing (TCP) was first documented as a technique in 1872.1 It was successfully demonstrated in two patients with underlying cardiac disease and symptomatic bradycardia.1 The clinical difficulty of open-chest pacing, transvenous pacing, and open-chest cardiac massage for the treatment of “ventricular standstill” in an emergent setting has been recognized.1,2 Animal experiments were performed using electrodes placed in various positions prior to the use of subcutaneous needle electrodes at points “in a line transversing the ventricles.”1 The use of the procedure during eight surgical cases in which cardiac arrest occurred resulted in five patients successfully surviving to discharge.2 Cardiac monitoring during surgery was not routinely performed and the underlying rhythm being paced was not specifically determined in all reported cases.

Further work related to TCP seems to have lapsed until the 1980s. Several groups studied the technique for treatment of symptomatic bradycardias, asystolic cardiac arrest, and bradyasystolic cardiac arrest in the hospital and in the Emergency Department.3 They concluded that TCP is as successful as transvenous cardiac pacing in obtaining electrical and mechanical capture in bradyasystolic arrests. TCP was easier to initiate than transvenous cardiac pacing. However, TCP did not improve the overall survival rates for these patients.3

TCP was recommended for cardiac emergencies by the International Liaison Committee on Resuscitation (ILCOR) guidelines beginning in 1980 and is currently recommended for treatment of symptomatic bradycardias, especially when the conduction block is at or below the His-Purkinje level.4 TCP is no longer indicated for the treatment of asystolic cardiac arrest since there are no improvements in rate of hospital admission or survival to hospital discharge.5

With current technology and equipment, TCP offers several advantages when compared to the placement of a transthoracic cardiac pacemaker (Chapter 42) or transvenous cardiac pacemaker (Chapter 43) in the Emergency Department. The procedure requires minimal training and can be performed quickly. TCP is a noninvasive procedure and is not associated with the major complications of placing more invasive pacemakers. This includes inadvertent arterial puncture, hemorrhage, pneumothorax, or cardiac tamponade from cardiac rupture. TCP is an ideal early and temporary intervention for patients requiring stabilizing cardiac pacing support until more invasive procedures can be arranged in the proper clinical setting.

ANATOMY AND PHYSIOLOGY

Electrical impulses originating in the sinoatrial (SA) node create an action potential that is conducted along the intrinsic cardiac nerve pathways to the atrioventricular (AV) node and disseminated through the His-Purkinje system. This action potential stimulates electrolyte flux, myocardial muscle depolarization, and subsequent cardiac muscle contraction. Electrical propagation and myocardial contraction occur separately in the atria and ventricles. The atria contract slightly ahead of the ventricles during ventricular diastole. This timing delay assists in filling the ventricles prior to their next ventricular systolic phase. The intrinsic heart rate is controlled by a balance of ...

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