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First documented as a technique in 1872, transcutaneous cardiac pacing (TCP) was successfully demonstrated in two patients with underlying cardiac disease and symptomatic bradycardia by Paul Zoll in 1952.1 Studies involving open-chest and transvenous pacing, as well as open-chest cardiac massage, were occurring simultaneously by other groups. Zoll recognized the clinical difficulty of these approaches for the treatment of “ventricular standstill” in an emergent setting.1,2 Zoll and colleagues performed animal experiments using electrodes placed in various positions prior to the use of subcutaneous needle electrodes at points “in a line transversing the ventricles” as described in the initial case report.1 In 1956, they described the use of their procedure during eight surgical cases in which cardiac arrest occurred, with five patients successfully surviving to discharge.2 At this time, cardiac monitoring during surgery was not routinely performed, thus the underlying rhythm being paced was not specifically determined in all reported cases.
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Further work related to TCP seems to have lapsed until the 1980s, when several groups studied the technique for treatment of symptomatic bradycardias, asystolic cardiac arrest, and bradyasystolic cardiac arrest both in-hospital and in the Emergency Department. The results of these investigations were summarized by Hedges et al.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
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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.4,5 TCP is no longer indicated for the treatment of asystolic cardiac arrest as there are no improvements in the rate of hospital admission or survival to hospital discharge in this setting.5–7
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With current technology and equipment, TCP offers several advantages when compared to the placement of a transvenous cardiac pacemaker 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 a transvenous cardiac pacemaker. 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.
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In the normal heart, 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, with the atria contracting slightly ahead of the ...