Reviewed Date: Supersedes (Policy #/description & date): Prepared by: Jacque Callis, RN Approved by: D.R. Johnson, MD

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1 External Pacemaker Set-up and Revised Date: 11/13/2014 Page 1 of 5 POLICY: The transcutaneous external pacemaker will be used as a noninvasive method of delivering electrical stimuli to the myocardium for the following indications: 1. Hemodynamically significant bradycardia or atrioventricular blocks. 2. Loss of function of pre-existing permanent pacemaker. 3. Overdrive stimulation to suppress ventricular ectopy. PURPOSE: A transcutaneous pacemaker (TCP) can serve as a standby pacemaker in potentially unstable patients and acts as a therapeutic bridge until placement of a transvenous pacemaker is inserted under more controlled circumstances. EQUIPMENT NEEDED: 1. Lifepak 12 (Biphasic Defibrillator/Monitor/Pacemaker) 2. Quik-Combo electrodes 3. Quik-Combo therapy cable 4. Patient ECG cable 5. Crash cart 6. Pulse oximetry/supplemental oxygen 7. ECG cable/electrodes PROCEDURE GUIDELINES: A. Setup and Operation: 1. Remove artificial devices for patient safety (e.g., glasses, dentures, contact lenses). 2. Inform patient of procedure (e.g., patient may feel twitching and thumping sensations). Consider sedation or analgesia. 3. Have crash cart immediately available. 4. Assess respiratory status (transcutaneous pacing may interfere with patient s breathing). 5. Administer supplemental oxygen. 6. Start IV line, if not already established. 7. Obtain baseline ECG. Include continuous pulse oximetry for adequate oxygenation during transcutaneous pacing. 8. Identify Quik-Combo electrode sites on the patient. Use either the anterior-lateral or anterior-posterior position.

2 External Pacemaker Set-up and Revised Date: 11/13/2014 Page 2 of 5 9. Prepare the patient s skin for Quik-Combo electrode application: Remove excessive hair. clip with scissors or shave if necessary, avoid cutting the skin. Clean the skin and dry. Briskly rub with a towel or gauze. Do not apply alcohol, tincture of benzoin, or antiperspirant to the skin. Check for medication patches on the torso and remove if present. Check for implanted devices, i.e., pacemaker or AICD. Do not apply Quik-Combo electrodes over implanted devices. 10. Attach monitoring ECG electrodes and cable to patient as follows: RA (right arm) = white, LA (left arm) = black, LL (left leg) = red. 11. Place the Quik-Combo electrodes in the anterior-lateral or anterior-posterior position and connect the therapy cable. 12. Press the ON button. NOTE: The Lifepak 12 defaults to the AED mode when turned on. Disable the AED mode to prepare for pacing by pressing the black ADVISORY button at the right of the screen.

3 External Pacemaker Set-up and Revised Date: 11/13/2014 Page 3 of Select Lead I, II, or III on monitor by pressing the LEAD button and using the selector to choose the best lead (usually lead II). To receive the best monitoring signal there must be adequate space between the ECG electrodes and the Quik-Combo electrodes (2 inches is optimal). 14. Press PACER button. a. Indicator light illuminates pacer button on front of monitor. Demand pacing message is displayed on lower portion of the monitor screen. b. For non-demand pacing (not usually used): Press the OPTIONS button and turn the selector knob until PACING is highlighted. Press in the selector knob to select. Turn the selector knob until NONDEMAND is highlighted; press the selector knob to select. Non-demand pacing message will be displayed on the lower portion of the monitor screen. 15. Observe Monitor Screen; triangle sense marker should appear on each QRS complex. a. If sensor marker is not present on the QRS or appears elsewhere, adjust ECG size for optimal sensing b. If this fails, select another lead or reposition the ECG electrode and readjust ECG size 16. Select desired pacing rate (pacemaker automatically starts at a rate of 60 PPM). Press RATE button or turn the selector knob to increase or decrease rate. Using the RATE button changes in 10 PPM increments, the selector knob changes in 5 PPM increments. 17. Prior to selecting the current, inform patient that pacing will begin 18. When the pacemaker is SENSING properly, activate pacing by pressing the CURRENT button multiple times or by turning the selector knob after pressing the button once, to increase current until CAPTURE is observed. For each delivered pacing stimulus the pacer indicator light flashes and a positive pacer spike is displayed on the ECG monitor screen. a. Initial current is set at 0 ma. The CURRENT button changes the current in 10 ma increments; the selector knob changes in 5 ma increments. b. Initial Settings: 1) Demand a) Set pacing rate at 10 beats greater than the patient s intrinsic rate. b) Set current at 10 ma and increase by 10 ma increments to the lowest level that achieves capture, or as ordered by physician. c) With currents of 50 ma or more sedation/analgesia may be needed to minimize discomfort. 2) Non-demand pacing mode if ordered by physician (found in OPTIONS menu, see above). 3) The PACER INDICATOR LIGHT flashes and a positive pacer spike appears with each pacing pulse.

4 External Pacemaker Set-up and Revised Date: 11/13/2014 Page 4 of Observe monitor for evidence of electrical pacing capture and effectiveness of pacing. a. Palpate patient s femoral pulse. (A carotid pulse should not be used for assessment of circulation as Transcutaneous Pacing can create muscular movements that may feel like a carotid pulse.) Check B/P to assess for perfusion (mechanical capture). b. Respiratory evaluation. c. Evaluate for 100% capture. Every pacing spike followed by QRS complex (greater than 0.14 milliseconds), a T wave, and suppress or competition with the patient s intrinsic beat. d. Observe rhythm for return of adequate intrinsic rate. 20. When pacing activated, recorder will document pacing capture. (Each pacing stimulus is marked with an arrow, on lower edge of ECG paper.) 21. To interrupt pacing and view the patient s intrinsic rhythm, press and HOLD the PAUSE button. This causes the pacer to pace at 25% of the set rate. Release the PAUSE button to automatically resume pacing at the set rate. The recorder will automatically print a strip when the pacer is paused. 22. Discontinue pacing only with physician s order. Termination is gradual (slowly decrease pacing rate and/or ma). To stop pacing, press pacer button again. The indicator light will go off. 23. Keep transcutaneous external pacing unit on standby for at least 24 hours after discontinuation of pacing and removal of electrodes in the event bradycardia or block returns. B. TROUBLESHOOTING: 1. Check power is on. Use auxiliary power supply if available (plug in the Lifepak 12 for prolonged pacing). 2. Assure pacing electrode (Quik-Combo electrode) is attached to patient (check when CONNECT ELECTRODES message is displayed). 3. Assure attachment of the pacing cable to Quik-Combo electrode. (Check when PACING STOPPED and CONNECT ELECTRODES message is displayed.) 4. Assure ECG leads attached to patient s chest. (Check when ECG LEADS OFF message is displayed.) ECG size must be properly adjusted. If ECG size is set too high or low, pacing pulse may not be delivered when required. Adjust size so that sense markers are placed on the QRS complexes.

5 External Pacemaker Set-up and Revised Date: 11/13/2014 Page 5 of 5 5. Shut off and restart pacing if pacing stops spontaneously or when PACER FAULT message is displayed. If continued failure, obtain alternate pacing device or another Lifepak Reposition electrodes for non-capture, high current requirements, or excessively painful stimuli (ma>90). When Quik-Combo electrodes are removed, do not reuse them. Apply fresh electrodes. 7. Observe patient continuously while pacemaker in use. Patient s response to pacing therapy (e.g., capture threshold) may change over time. 8. Inspect electrodes to make sure adhesive is intact and undamaged. Do not use electrodes beyond expiration date. Do not use electrodes if removed from package > 24 hours or if protective liner has been removed > 60 minutes. Assure proper Quik-Combo electrodes are used for adult or pediatric/infant use. REFERENCES: American Heart Association, Online guidelines for ACLS Medtronic Physio-Control, LIFEPAK 12 3D BIPHASIC Operating Instruction Manual, January Date Chief Nursing Officer Date