Emergency department use of transcutaneous pacing for cardiac arrests

Transcutaneous cardiac pacing is a rapid technique for pacing the heart using skin electrodes to pass repetitive electrical impulses through the thorax. This paper reports the results of transcutaneous pacing in a series of 52 emergency department patients. Patients were selected for pacing if they were unconscious and in asystole (30 patients) or unconscious with a pulseless or hemodynamically ineffective bradycardia (22 patients). In all cases, transcutaneous pacing was attempted after initial resuscitative drug therapy failed. Of the 26 patients with successful ECG capture, 14 were initially in asystole, 11 were initially in a pulseless bradycardia, and one had a hemodynamically ineffective bradycardia. Of the eight patients developing a pulse, four developed a measurable BP. The four patients who developed a measurable BP were young (ages 22 to 39 yr) and only one had an underlying cardiac etiology for his cardiac arrest. No patient survived to be discharged from the hospital. Twenty-five of the 52 patients also had a transvenous pacemaker inserted, with successful electrical capture in five of the patients. Only one of the transvenously paced asystolic patients subsequently developed a BP. There were no patients successfully paced transvenously who were not successfully paced transcutaneously.     

Emergency noninvasive external cardiac pacing

Thirty-seven critical emergency department patients underwent attempts at external cardiac pacing over an 11-month period. Indications for pacing were asystole in 16, complete heart block (CHB) in 4, sinus bradycardia in 2, nodal bradycardia in 1, atrial fibrillation with bradycardia in 2, electromechanical dissociation in 1, idioventricular rhythm (IVR) in 10, and torsades de pointes in 1. Eight patients were successfully paced with improvement in their condition. Two were in asystole, two in CHB, three in sinus rhythm or atrial fibrillation with bradycardia, and one in idioventricular rhythm. Mean systolic blood pressure rise with pacing was 95 +/- 50 mm Hg. Six of these patients were ultimately discharged from the hospital. One asystolic patient survived to discharge. Other survivors presented with either CHB or bradycardia. Of the 29 patients who did not respond to pacing, 5 survived to hospital discharge. Surviving nonresponder presenting rhythms were CHB in one patient, sinus or nodal bradycardia in two, IVR in one, and torsades de pointes in one. External cardiac pacemaking appears to be effective in hemodynamically significant bradycardia. It does not appear to be effective in most instances of asystole or IVR resulting from prolonged cardiac arrest. When applied to patients with a responsive myocardium, it may result in significant hemodynamic improvement and may be lifesaving.     

环状钢丝电极补救性经胸壁紧急心脏起搏的临床应用

目的 探索一种补救性紧急心脏起搏的有效方法,并评价其临床应用情况.方法 18例住院期间发生心搏骤停或缓慢心率患者,在常规经锁骨下或颈内静脉途径紧急心内膜起搏,但因穿刺静脉未成功或起搏电极未进入右心室,而采取补救性经胸壁环状钢丝紧急心内膜心脏起搏.结果 5例心室起搏未夺获心室;其余13例均可起搏夺获心室,未发生心脏压塞的严重并发症.11例患者有效起搏心脏并抢救成功,其中心脏静止3例,心室纤颤经电击除颤后心脏停搏2例,室性心动过速同步电复律后心脏停搏1例,Ⅱ度或高度房室传导阻滞伴极缓慢交界性逸博4例,高血钾伴极缓慢室性心率1例.8例成功夺获心室者心脏停搏至心脏穿刺时间较5例起搏未成功夺获心室者明显缩短[(17.6±4.6)min比(26.4±5.4)min,P＜0.05].结论 环状钢丝电极经胸壁紧急心内膜心脏起搏是一种安全可靠的心脏紧急起搏方法;有助于迅速建立有效的紧急心脏起搏.当常规经静脉途径心脏起搏不成功时,应果断改用经胸壁钢丝电极紧急心内膜心脏起搏,以提高抢救成功率.     

External cardiac pacing for out-of-hospital bradyasystolic arrest

Cardiac pacing has been used successfully in patients with asystole or bradycardia compromising hemodynamics when it was applied soon after the onset of the event. An external cardiac pacemaker was used as part of initial resuscitative efforts for patients in primary, out-of-hospital, cardiac arrest who arrived in the emergency department in asystole, agonal rhythm, pulseless idioventricular rhythm, or bradycardia with hemodynamic compromise. A pulse was successfully generated in only one of twelve patients. That patient developed complete atrioventricular dissociation while in the emergency department. The nonresponding patients were in asystole or pulseless idioventricular rhythm when the pacemaker was applied. Pacing was initiated 1-13 minutes (mean 7 minutes) after arrival in the emergency department, but 27-90 minutes (mean 59 minutes) after arrest. The interval between arrest and application of the pacemaker was prolonged because of long periods for ambulance response, field resuscitation, and transport. It is concluded that the external cardiac pacemaker is a useful instrument for the treatment of bradyarrhythmias. While it may also be useful in the first few minutes after development of asystole, pulseless idioventricular rhythm, or agonal rhythm, it is of no benefit if applied long after the event.     

Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole.

Pacing is a well recognised treatment in asystolic arrest with residual p wave activity. This can be achieved by transvenous, transthoracic, or manual external (cardiac percussion) pacing techniques. We report a case of ventricular asystole in which all three pacing modalities were applied, and demonstrate their relative effectiveness with invasive haemodynamic monitoring data. Stroke volumes were comparable with all three methods. Manual external pacing is an effective holding measure when cardiac output is compromised due to bradycardia or asystole with residual p wave activity before more definitive pacing techniques are instituted.     

床边紧急心脏起搏在急诊急救中的应用价值

目的 探讨床边紧急漂浮临时心脏起搏在急诊抢救中的应用价值及优越性.方法 回顾性分析内蒙占医学院第一附属医院近4年床边紧急漂浮临时心脏起搏130例和70例x线指导下临时心脏起搏抢救各种病因引起严重的缓慢型心律失常患者.结果 130例床边紧急漂浮临时心脏起搏患者成功起搏127例(97.69%),电极未到位3例(2.31%),电极脱位3例(2.36%),无严重并发症发生.从就诊到操作开始的时间为5-15 min,穿刺到成功起搏的时间为(4 4±2.5)min;70例x线指导下临时心脏起搏患者成功70例(100%),脱位6例(8.57%),下肢静脉血栓1例(1.43%),心肌穿孔致心包填塞2例(2.86%),从就诊到操作开始的时间为30-90 min,穿刺到成功起搏的时间平均为(3.5±1.5)min.结论 应用床边紧急漂浮临时心脏起搏救治严重缓慢型心律失常方法简便、并发症少,是一种及时、安全、有效的抢救措施,可在急诊急救中推广应用.     

Intravenous theophylline--an alternative to temporary pacing in the management of bradycardia secondary to AV nodal block

OBJECTIVE: To report a case of bradycardia secondary to atrioventricular nodal block (AVNB) successfully treated with intravenous theophylline. Intravenous theophylline was used as an alternative to temporary pacing in a patient with sepsis secondary to thermal injury. CASE SUMMARY: A 79-year-old white woman with significant cardiac history was admitted with 14.5% total body surface area burns after a house fire. Cardiac events included intermittent episodes of sinus bradycardia complicated by the development of second-degree AVNB and periods of sinus arrest. Intravenous theophylline initiation maintained normal sinus rhythm without further episodes of sinus bradycardia or heart block, thus preventing the need for cardiac pacemaker placement. DISCUSSION: This is the first case published in the English-language literature describing the use of intravenous theophylline as an alternative therapy to temporary pacing in a patient with sepsis secondary to thermal injury. Bradyarrhythmic events in sepsis patients have been associated with catecholamine production increasing adenosine formation. High concentrations of adenosine in the areas of the sinoatrial or atrioventricular nodal regions may induce sinus bradycardia or AVNB. Theophylline, an adenosine antagonist, has been identified as a treatment option for such bradyarrhythmic events. CONCLUSIONS: Theophylline, a methylxanthine derivative, may represent an alternative to other pharmacologic therapies and temporary pacing in the treatment of bradycardia secondary to AVNB. These agents may represent a pharmacologic alternative in patients in whom other pharmacologic strategies or cardiac pacemaker insertion may be contraindicated.     

Successful resuscitation using transcutaneous cardiac pacing

Reported here is the case of a patient suffering from hemodynamically significant bradycardia in which the use of transcutaneous cardiac pacing resulted in successful resuscitation, obviating the need for invasive pacing. During pacing, intra-arterial recordings of blood pressure demonstrated higher pulse pressures for paced beats than for the patient's own escape beats. Recent data regarding the use of non-invasive transcutaneous cardiac pacing is also reviewed.     

Improvised transvenous cardiac pacing during Operation Enduring Freedom

We report a case of combat cardiology at a military medical facility in Afghanistan. The patient had a high-degree heart block following inferior ST-elevation myocardial infarction requiring cardiac pacing. Transcutaneous pacing failed, leading to asystolic arrest during critical care air transport. An available transvenous pacing wire was soldered to leads from transcutaneous pacing pads allowing effective in-flight cardiac pacing until definitive therapy was available. This case demonstrates use of available resources under austere conditions, has the potential to inform physicians in similar circumstance, and addresses an area of need at military medical facilities.     

临时心脏起搏在急性中毒并严重缓慢心律失常的疗效研究

目的 探讨在临时心脏起搏术支持下对急性中毒并严重缓慢心律失常进行中毒抢救的,临床意义.方法 对38例急性中毒并严重缓慢心律失常患者在急诊救治过程中随机采用临时心脏起搏器治疗(起搏组,18例)和药物治疗(对照组,20例),再进行解毒治疗.结果 起搏组18例经床旁临时心脏起搏术右心室起搏成功并置入临时心脏起搏器,配合解毒治疗措施后心律失常改善有效率为100%,而对照组为60%,2组比较差异有统计学意义(x2=19.7,P<0.01).中毒治愈率起搏组为88.9%,对照组为65.0%,2组比较差异有统计学意义(x2=8.2,P<0.05).结论 床旁临时心脏起搏术在抢救急性中毒并严重缓慢性心律失常患者的疗效确切,能有效提高患者的抢救成功率.     

Transcutaneous Pacemaker Use in a Large Hospital

For an eight-month period temporary transcutaneous and transvenous pacemaker use was analyzed in a 602-bed hospital which had readily available fluoroscopy. Twenty-four patients were treated with transcutaneous pacemaker; 23 of these were treated for asystole during cardiac arrest. The only patient not suffering cardiac arrest could not tolerate the transcutaneous pacemaker because of pain. Two of these 23 patients were treated early in the arrest with successful resuscitation. They became conscious and were able to tolerate the pacemaker well. Most of the other patients were treated late in the arrest with little chance of any therapy being successful. Only four of these 21 patients were treated within 15 minutes of the onset of cardiac arrest. During the same time span, 23 patients received transvenous temporary pacemakers. Only four of this group had suffered cardiac arrest before pacing.
We conclude that: (1) transcutaneous pacing can be successful but we did not find it useful when used late in a cardiac arrest; (2) transvenous pacing seemed the approach most often chosen for the non-arrest situation.     

Delayed asystolic cardiac arrest after diltiazem overdose; resuscitation with high dose intravenous calcium

A 51 year old man took a mixed overdose including 1.8-3.6 g of diltiazem, paracetamol, aspirin, isosorbide nitrate, and alcohol. He initially presented to hospital after six hours with mild hypotension and was treated with activated charcoal and intravenous fluids. Eighteen hours after the overdose he had two generalised tonic-clonic seizures. The patient remained unresponsive with junctional bradycardia, unrecordable blood pressure, and then became asystolic. He was resuscitated with high dose (13.5 g) intravenous calcium and adrenaline (epinephrine). He required inotropic support and temporary pacing over the next 48 hours. This case suggests there is a role for aggressive high dose intravenous calcium therapy in severe diltiazem overdose, particularly with the onset of asystole. It should be considered early in cases of cardiac arrest after diltiazem overdose. The case also highlights the problems with delayed toxicity when whole bowel irrigation is not administered.     

A comparison of transoesophageal cardiac pacing and epinephrine for cardiopulmonary resuscitation

The use of cardiac pacing to deal with bradycardia is well established. There is debate as to the benefits during cardiopulmonary resuscitation (CPR). This study was performed to compare the effects of transoesophageal cardiac pacing and high-dose epinephrine on the benefits of cardiopulmonary resuscitation after asphyxial cardiac arrest in rats. Thirty Sprague-Dawley rats of both sexes were randomly selected to a saline group (Sal-gro, treated with normal saline 1 mL IV, n = 10), an epinephrine group (Epi-gro, treated with epinephrine 0.4 mg/kg IV, n = 10), or a pacing group (Pac-gro, treated with normal saline 1 mL IV combined with transoesophageal cardiac pacing, n = 10) in a blinded fashion during resuscitation after 10 minutes of asphyxial cardiac arrest. Manual chest compression was in all cases performed using the same methodology by the same personnel who was blinded to hemodynamic monitor tracings. The rate of restoration of spontaneous circulation was 1 (10%), 7 (70%), and 8 (80%) of 10 in Sal-gro, Epi-gro, and Pac-gro, respectively. The rate of ventilator withdrawal within 60 minutes after resuscitation in Pac-gro was higher than that of Epi-gro (8/8 vs 1/7, respectively; P = .001); the survival rate after 2 hours in Pac-gro was significantly higher than that in Epi-gro (7/8 vs 1/7, respectively; P = .01). The data demonstrate that both epinephrine and transoesophageal cardiac pacing are effective within 10 minutes of asphyxia in rats. It is worth noting that transoesophageal cardiac pacing produced a better outcome with respiration and longer survival time compared with epinephrine after restoration of spontaneous circulation.     

Electrical therapies in cardiac arrest

Recognition and appropriate treatment of ventricular fibrillation or pulseless ventricular tachycardia is an essential skill for healthcare providers. Appropriate defibrillation can improve survival and benefit patient outcome. Similarly, increased public access to automatic electronic defibrillators has been shown to improve out-of-hospital survival for cardiac arrest. When combined with high-quality cardiopulmonary resuscitation, electrical therapies are an important aspect of resuscitation in the patient with cardiac arrest. This article focuses on the use of electrical therapies, including defibrillation, cardiac pacing, and automated external defibrillators, in cardiac arrest.     

Cardiac arrest due to a vagal reflex potentiated by thoracic epidural analgesia

Reflex bradycardia and cardiac arrest may be the result of a vagal reflex, which can occur during a variety of surgical procedures. We report a patient who developed cardiac arrest as a result of a vagal reflex that was potentiated by thoracic epidural analgesia during general anaesthesia. A 53-year-old man was scheduled for subtotal gastrectomy because of an early gastric adenocarcinoma. After an epidural catheter had been inserted, general anaesthesia was induced. During surgery, an abdominal self-retaining retractor was set up but bradycardia and cardiac arrest developed. The patient returned to a normal sinus rhythm after successful resuscitation. We conclude that bradycardia as a result of a vagal reflex is mediated by potent abdominal wall traction and is potentiated by epidural analgesia. Early diagnosis and proper treatment can allow a full recovery, even in high-risk patients.     

Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a systematic review

BACKGROUND: Advanced cardiac life support (ACLS) guidelines suggest transcutaneous cardiac pacing (TCP) for the treatment of symptomatic bradycardia (SB) and bradyasystolic cardiac arrest (BACA). Many EMS systems are extrapolating these guidelines and employing TCP in the prehospital setting. Our objective was to conduct a systematic review to determine the efficacy of prehospital TCP in the management of these two conditions. METHODS: MEDLINE (1966-2004), EMBase and Science Citation Index (1980-2004) were searched using: prehospital/emergency medical services; external/transcutaneous; pacing. Two reviewer teams blinded to the source and author conducted a hierarchical selection (title, abstract, article) and quality assessment using a validated scale. Kappa agreement at each level of review was measured. Data abstraction was done by consensus. RESULTS: Thirty-four articles were identified and seven selected (Kappa agreement; title: 0.85, abstract: 0.78, full article: 0.82). Article quality was poor in all trials. There were three case series (BACA, n=215), three unblinded randomised controlled trials (one BACA, two BACA+SB), and one subgroup (SB) analysis. In the case series of paced BACA patients, 0/215 survived to hospital discharge. In the BACA trials 16/509 (paced) versus14/497 (control) survived to discharge. In a subgroup of one SB trial 5/6 (paced) versus 1/7 (control) survived to discharge (p=0.01). When a SB trial subgroup was combined with a case series 4/27 (paced) versus 0/24 (control) survived to discharge (p=0.07). CONCLUSIONS: In the prehospital setting, there is no evidence to support the use of TCP in bradyasystolic cardiac arrest. There is inadequate evidence to determine the efficacy of prehospital TCP in the treatment of symptomatic bradycardia.     

Bradycardia and Syncope in Children Not Controlled by Pacing: Beta-Adrenergic Hypersensitivity

Cardiac pacing is frequently employed in the therapy of children with syncope and documented bradycardia. This report describes two children, ages 7 and 9 years, who underwent placement of demand ventricular pacing systems for documented bradycardia and syncope. Cardiac catheterization and intracardiac electrophysiological studies failed to show evidence of structural abnormalities, sinus node or conduction system disease, inducible arrhythmias, or VA conduction in each patient. Both patients had persistent symptoms after pacemaker implantation. Autonomic function testing with continuous heart rate and blood pressure monitoring revealed exaggerated beta-adrenergic responses to simple standing and small doses of isoproterenol. Symptoms were completely eliminated with atenolol. In these two children, cardiac pacing alone was not adequate for relief of symptoms. Autonomic mechanisms of bradycardia and hypotension should be considered prior to implantation of permanent pacing systems in children.     

Emergency Cardiac Pacing for Severe Bradycardia

ALTAMURA, G., ET AL.: Emergency Cardiac Pacing for Severe Bradycardia. Our study included the treatment of transcutaneous cardiac pacing (TCP) in 32 patients: (A) 19 patients were treated in the emergency area for complete symptomatic AV block before endocavitary pacing; (B) five patients were in asystole following DC shock or out-of-hospital cardiac arrest; and (C) eight patients were affected by bifascicular block undergoing emergency surgery and were treated in order to prevent complete AV block. Two transcutaneous stimulators were used. PaceAid-CRC model 50/52 with 20-msec pulse width; the electrodes were positioned on the V, ECG position and on the back. Results: in all but two patients, it was possible to obtain stable cardiac capture; in one patient arrived in hospital in asystole after prolonged cardiac arrest and in the other one was affected by complete AV block, TCP was ineffective. In groups A and B, TCP was maintained for a mean time of 15 minutes; in group C, TCP was tested in all patients, but performed in only one patient during surgery. Mean threshold was 81 mA. Stimulation was well tolerated in all but five patients. TCP is a reliable, noninvasive method that offers the possibility to initiate pacing within seconds and can be used by medical staff. In our opinion, it should be considered as the first choice emergency treatment of severe symptomatic bradycardia. In asystole, beneficial effects can be obtained only if TCP is performed early enough after the onset of arrhythmia.     

The Role of Implantable Cardioverter Defibrillators in Non VT/VF Sudden Deaths

Implantable cardioverter defibrillator (ICD) therapy has been an impressive success in preventing sudden cardiac death (SCD). Electrocardiographic documentation of SCD in ICD patients has been rare, but usually arrhythmias other than ventricular tachycardia/ventricular fibrillation (VT/VF; asystole and electromechanical dissociation [EMD]) have been implicated. This raises the question whether backup bradycardia pacing can prevent deaths due to asystole and EMD in such patients. We studied the outcome of 88 patients with permanent bradycardia pacemakers and compared them to 500 consecutive nonpacemaker patient controls, sustaining out-of-hospital cardiac arrest and undergoing resuscitation by paramedics. Mean age of the pacemaker patients was 73.5 ± 10.3 years and 64% males, compared to mean age of 68.2 ± 6.7 years and 67% males in the control group. Overall success of resuscitation and survival rates were similar. When the documented rhythm was VT/VF or asystole there were no differences in resuscitation or survival rates for the pacemaker or nonpacemaker patients. However, resuscitation rate was significantly higher in pacemaker patients than nonpacemaker patients with EMD: 47% versus 20% ( P < 0.03). For EMD, survival rate for the pacemaker patients was 13% compared to 5% in the nonpacemaker patients, but this difference was not statistically significant. Backup bradycardia pacing in future generation devices may improve the outcome of non VT/VF sudden cardiac death in at least some of the ICD recipients.     

A Comparison of VVIR and DDDR Pacing Following Cardiac Transplantation

We compared the clinical course of patients paced in VVIR versus DDDR mode to determine the most appropriate method of pacing following cardiac transplantation. Pacemaker implantation was required in 9 of 90 orthotopic cardiac transplants (10%). Indications included sinus bradycardia or sinus arrest (8 patients) and AV node dysfunction (1 patient). VVIR pacemakers were implanted in four patients and DDDR in five patients. DDDR patients : The mean P wave was 1.7 mV and the mean atrial stimulation threshold was 0.8 V (at 0.5 msec). During follow-up of 20 months, two atrial lead complications developed (29% of leads in 33% of patients). No lead complications were directly related to endomyocardial biopsy. VVIR patients : All four patients developed VA conduction with mean VA time 180 msec (160–240 msec). Two patients developed pacemaker syndrome. Conclusions : VA conduction and pacemaker syndrome may develop in cardiac transplant recipients paced in the VVIR mode. Dual chamber pacing is technically feasible and preferable following cardiac transplantation.