Dr. Peter Antevy explains pediatric transcutaneous pacing for severe bradycardia from heart block or sinus node dysfunction. Use pediatric pads for kids under 2 years, adult pads for 3 and up. Start at 10 mA and increase by 10 mA until you see electrical capture, then set output 5 to 10 mA above that threshold.
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Hi, it's Dr. Peter Hantevi. Welcome to another edition of the Hantevi Minute. Today I'd like to discuss a topic that many people ask me about pediatric transcutaneous pacing. Pacing is a life saving procedure used in critical situations when pediatric patients experience severe bradycardia or heart block. Today, I'll walk you through the steps involved in this essential intervention. So let's start by understanding when transcutaneous pacing is indicated for pediatric patients. Picture a pediatric patient with altered mental status and bradycardia caused by complete heart block or sinus node dysfunction. In this child, you should immediately begin cpr, focusing on ventilation, oxygenation, chest compressions and and medications. Now, if those interventions do not improve the bradycardia, it's at this point that pacing may be indicated. A quick reminder that the AHA currently recommends a cardiac arrest dose of epinephrine for symptomatic bradycardia. Even though the 2019 Holmberg study showed worse outcomes, my agencies have switched to push pressor EPI in these situations. Now, it's crucial to recognize that in these critical cases where other interventions have been unsuccessful, transcutaneous pacing can provide a lifeline to these young patients. A more exhaustive list of patients who may require pacing is shown here. Be sure to keep this differential at hand when treating a child with bradycardia. It's also important to be aware of the contraindications to pacing. The procedure should not be performed in cases of bradycardia due to severe hypothermia or during asystolic cardiac arrest. Severe hypothermia often accompanies significant systemic dysfunction and can impact overall metabolism and organ function. In those cases, the priority is to address the underlying hypothermia and provide rewarming measures to restore normal body temperature. Treating the hypothermia can often help restore the heart's natural electrical conduction, and it may eliminate the need for external pacing. So let's delve now into the procedure itself. The typical patient you'll likely be attempting pacing on is a child who is actively receiving cpr. Therefore, sedation and pain management are not of concern. You may encounter conscious patients who are symptomatic where CPR is not indicated and and in those patients you should sedate them using medications like etomidate or midazolam. Also consider pain management with fentanyl or morphine, or alternatively you can consider ketamine, which provides sedation and pain control. Now, before proceeding, we must assess several factors to ensure the patient is ready. These include maintaining a patent and secure Airway. And as I mentioned earlier, CPR may be already in progress. Now let's set up the monitoring equipment. First, initiate four lead cardiac monitoring, which is crucial for effective pacing. It's essential to place the monitoring leads correctly to obtain accurate readings. Next, apply combo pads to the patient in either anterior posterior placement, which is preferred, or anterior lateral placement. Pediatric combo pads are used for patients aged preemie to two years old, while the adult combo pads are used for patients age 3 and older. Now let's talk about the pacemaker settings. Make sure the monitor is set to a LIM lead. Turn on the pacing function and set the rate between 80 and 100. For pediatric patients, confirm the current is defaulted to 0 milliamps. To confirm that the pacemaker is recognizing QRS complexes, it will evaluate the ecg. If it's not recognizing them, adjust the size and or lead selection.
Starting at 10 milliamps, increase the amperage in 10 milliamp increments until electrical capture occurs. You'll know you have electrical capture when you see the pacer spike followed by a wide QRS complex, the lowest output at which capture is achieved. Now that's called the pacing threshold. To maintain reliable pacing, you should set the final output five to 10 milliamps above that pacing threshold.
Alright. Let's transition to a full screen view of the LifePak to delve into the details of transcutaneous pacing. How it works is straightforward. The electrodes administer an electrical stimulus to the heart, causing cardiac depolarization followed by myocardial contraction. Whether you're using the LifePak or the Zoll, both monitors are equipped to provide pacing in two modes, demand and non demand. Here I'll demonstrate using the LifePak 15 by default, once the limb leads are placed, the LifePak initiates pacing in demand mode. What this means is that the LifePak will stop pacing when it detects the patient's intrinsic rate surpasses the rate that you have set. It's an automatic shutdown mechanism designed for the patient's benefit. The pacing we just demonstrated in the last segment utilize demand mode and that's suitable for the majority of patients. In contrast, we have non demand pacing, also known as asynchronous or fixed rate pacing. In this mode, the device puts out a consistent rate of electrical impulses regardless of the patient's intrinsic rhythm. This mode does not have the automatic adjustment I mentioned. With demand pacing, the machine maintains the same rate irrespective of what's happening with your patient during cpr. Non demand mode is the better choice because chest compressions can interfere with the ecg, preventing the sense markers from identifying the QRS complexes. Okay, so let's walk through the process of switching to non demand pacing mode on the monitor. First, select Options on the LifePak, then scroll to Pacing and select that. Now choose the mode options, scroll to and select non demand. Now you'll see that this menu also allows for turning the internal pacer detection.
On or off, but this isn't relevant.
To our current discussion. So from here, return to the home screen and operate the pacer menu as I've just described.
Okay, it's important to check for mechanical capture by assessing the patient's pulse. If the pulse rate is significantly lower than the pacing rate displayed on the monitor, that may mean that you do not have capture. If a femoral pulse is not palpable for each captured and conducted beat, immediately contact medical control for further instructions. If a femoral pulse is palpable, assess the patient's blood pressure. If capture fails to occur at the maximum milliamp setting 200, discontinue pacing and immediately contact medical control. And if at any point the patient loses palpable pulses, start CPR immediately and refer to the cardiac arrest protocol. Here's one final important point. It's about transferring your pace patient over to the hospital staff. Here's how that should go down. The receiving facility should place a new set of pads on your patient as well as a new set of limb leads. Ensure that the QRS is being sensed correctly, and then set the same rate and milliamps as the transporting monitor. Finally, start pacing on the hospital monitor and then quickly turn down the milliamps on the transporting monitor. I want to give a big shout out to Dr. Mike Levy from Anchorage, Alaska, who gave a wonderful presentation at the 2023 Eagles on this important topic. In closing, transcutaneous pacing in pediatrics is a critical intervention that can save lives. Follow these steps to ensure effective pacing to provide the best possible care for your patients in need. Remember, your expertise in quick actions make a significant difference in their outcomes. Thank you for your.
