Transvenous Pacemakers

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Nurses Edition Commentary

Mizuho Morrison, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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Allan M. -

Great Chapter.
At our place, we don't have isoprotenerol. Although I get that we could use the simple push Epi, what do you think about dobutamine?


Joe Bellezzo -

Allan, good question. Physiologically, you are probably right - on paper dobutamine should be similar to Isoprel for treating symptomatic bradycardia - although the dog study (below) from 20 years ago (!) would suggest: 1. dobutamine for contraction and 2. Isoprel for rate. But I have no other good evidence to prove it.

One (minor) point here was that you can push isoprel (if you have it). I have it and have used it many times for this indication and it works beautifully to increase HR temporarily (until you get the TV pacer in).

Pragmatically, epinephrine is a better choice because it is universally available on every crash cart and I can do a 1:10 dilution > push 1 ml (10 mcg) and repeat as necessary. Dobutamine is not available as push dose. So by the time you order the med, get it cleared from pharmacy, set up the pump, etc, you already have your pacer in!

If you don't have isoprel (or even if you do but it isn't convenient to get), push some epi and/or start a dirty epi drip while you are prepping your TV pacer.

In Dogs in 1975: Am J Cardiol. 1975 Dec;36(7):894-901.
In rats in 2012: European Journal of Anaesthesiology. June 2012 - Volume 29 - Issue - p 75–76
In humans:

Rabbott -

A few quick notes about history and cross border differences: when I went into the ER business in 1973, transvenous pacers were just starting to be available in ER's. We used atropine and Isoproteronol. But Isoproteronol is a vasodilator and prone to tachydysrhythmias and hypotension. No surprise that the complications of Isuprel pushed us to a better approach, and transvenous pacers placed by ER Docs became more popular. However, when I worked in Tasmania (no it's nowhere near Romania, it's part of Australia) a few years ago, I saw surprising numbers of people with symptomatic bradycardia - I guess the Ozzies, unlike American cardiologists sending their kids to Stanford, don't provide everyone with a pacer for their 65th birthday. But, not a pacer wire or box to be seen in the ER. Run them on an epi drip, cards would turn it off the next day, and if they were still slow, put in a permanent pacer in the cath lab. The epi seemed to work very well - no hypotension, and nary a bout of excessive tachycardia. I guess the cost benefit ratio changes dramatically when you use the right drug, and compare the drug complications with the complications of relatively inexperienced ER Docs placing catheters (including the complication of failure to get the catheter where it belongs). After that experience, I tend to go with the epi drip rather than a rapid transvenous pacer placement.

Joe Bellezzo -


Your points are well appreciated! An epi drip, or isoprel drip, is also a very acceptable option for unstable bradycardia. Those options do work very well and are acceptable alternatives - no question. My argument here is not to establish the invasive approach as any form of standard of care.

But, for the emergency practitioner out there who is nervous about placing a TV pacer for the unstable bradycardic assured that the procedure is simple, straight forward, will temporize the problem for reasonable amount of time, and has few complications.

If you can place a central line in the IJ, you can place a TV pacer...with just a few more steps.

My message: don't be afraid of placing a TV pacer.

Christopher B. -

The AHA has slightly different recommendations for TV pacemaker placement in their 2013 STEMI (guidelines

"First-degree AV block does not require treatment. High-grade AV block with inferior/posterior STEMI usually is transient and associated with a narrow complex/junctional escape rhythm that can be managed conservatively. Application of transcutaneous pacing pads for potential use is reasonable. Prophylactic placement of a temporary pacing system is recommended for high-grade AV block and/or new bundle-branch (especially LBBB) or bifascicular block in patients with anterior/lateral MI."

They further make the point that inferior/posterior ischemia leads to transient vagal stimulation and therefore transient AV block. Alternatively, anterior/lateral ischemia affects the conduction system directly and is less likely to resolve.

Christopher B. -

Nice episode. To add further, there are certain etiologies of unstable bradycardia that don't respond well to TV pacing. These tend to be cases where the conduction system itself is poisoned. In the case of hyperkalemia, CCB or beta-blocker OD, or digoxin OD (to name a few) a specific antidote is likely to be more effective than pacing.

Atif F. -

You took the words outta my mouth! First of all, Drs Orman and Belezzo you guys are awesome, and your reviews are great. I never looked at torsades the same way after you two (funny, torsades keeps getting auto corrected to tornadoes, perhaps quite appropriately).

We actually had a bradycardia ESRD pt who was about to get a TVP until the pt turned around with a push of calcium. Perhaps the unstable near-arrest rhythms can just be approached as if it actually is an arrest, and it would be easier to remember to intervene in this way while prepping the TVP. As long as you Never Carry Bling Through Gloomy Antwerp :)

Joe Bellezzo -

Christopher...I couldn't agree more. It ain't easy to capture all the caveats in a short segment...but these are really good point. Also beware of the profoundly hypothermic patient and the mechanical tricuspid valve.

Laurence E. -

Great and important episode! You guys are 100% right and all ED docs should be comfortable with this procedure, especially for those who work in community hospitals where resources are not available 24/7! The most skilled part of the procedure is putting in the central line, which every ED doc is capable of doing.

A few points:
1. In undifferentiated unstable bradycardia, I always presumptively treat for hyperkalemia until the potassium is back. I also ask the lab to rush the potassium for me.

2. I would be hesitant to discourage transcutaneous pacing while you are getting the transvenous pacer in. I agree with trying epinephrine and that transcutaneous is poorly tolerated and complicates transvenous placement. However, many patients come in being transcutaneously paced by EMS and when you stop it to check the rhythm you can quickly watch them become unresponsive. Often, I will leave them being paced at least until the sheath is in and the wire is inserted and ready to be floated into the heart. Another technique is to set the transvenous pacer to 90 and turn down the transcutaneous pacer to 60, then once you have mechanical capture at 90 - you know it is time to turn the torture machine off.

3. It is likely a matter of style, but I start with a setting of only 5mA on the pacer when I am floating it. If you need more than that (usually less), you are in the wrong place.

4. Practice (with your nursing staff) and become familiar with your equipment BEFORE you have an unstable patient and the S hits the fan.

-Larry Edelman, M.D.

Joe Bellezzo -

Larry, Great points all around! To your thoughts:

1. For unstable brady, I do the same as you. I begin treating hyperK until the labs are back. Very little harm in that and may be profoundly helpful

2. Sure, if the TC pacer is already in place and happens to be working, then knock yourself out...keep using until you get the TV pacer in. Just beware that you could be masking VF with those giant pacer spike artifact! I like your tip of setting the TV pacer rate higher than the TC pacer rate to confirm TV capture. GREAT tip!

3. Good point. I just take the whole question of "am I using enough energy" completely out of the equation. 20mA ain't gonna hurt anything for a few minutes...

4. Yes indeedio!


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