External Pacing 

AHA - AED revised 12-12-03

SECTION 3

HOW TO EXTERNAL PACE

AND

AHA-AED PROTOCOL

 

 "HOW TO" EXTERNAL PACE

THE LIFEPAK 10 DEFIBRILLATOR/MONITOR WITH OPTIONAL PACEMAKER IS DESIGNED FOR DEMAND MODE PACING. FOLLOW USUAL PROTOCOLS FOR PATIENTS REQUIRING NONINVASIVE PACING INCLUDING SUPPORT OF AIRWAY, BREATHING AND CIRCULATION, AND DRUG THERAPY.

 

PROPER FUNCTIONING OF THE DEMAND MODE PACEMAKER IS DEPENDENT ON CORRECT OPERATOR ADJUSTMENT OF THE ECG SIZE TO ALLOW SENSING OF INTRINSIC CARDIAC ACTIVITY. THE LIFEPAK 10 DEFIBRILLATOR/MONITOR SENSES INTRINSIC QRS ACTIVITY AND INHIBITS THE PACING STIMULI FOR THE CYCLE. IF QRS ACTIVITY IS NOT SENSED BECAUSE ECG SIZE IS SET INCORRECTLY OR ECG LEADS ARE DETACHED, DEVICE PACES ASYNCHRONOUSLY AT THE SELECTED RATE.

 

THE PACING PROCEDURE OUTLINES PROPER ELECTRODE PLACEMENT AND CABLE CONNECTIONS. FOLLOW THE PROCEDURE; MISPLACING THE ELECTRODES OR REVERSING THE PACING CABLE CONNECTORS CAN MAKE A SIGNIFICANT DIFFERENCE IN CAPTURE THRESHOLD.

 

WARNINGS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ECG MONITORING DURING PACING

 

MONITORING DURING PACING MUST BE DONE THROUGH ECG ELECTRODES AND THE ECG CABLES RATHER THAN THROUGH THE PADDLES. DURING PACING, THE CARDIOSCOPE DISPLAYS PACE MARKERS FOLLOWED BY ANY RESULTANT QRS COMPLEXES. THE RECORDER ANNOTATES PACING INFORMATION AND DOCUMENTS EACH DELIVERED PACING STIMULUS WITH A BOLD-FACED ARROW (­ ) IMMEDIATELY BELOW THE STIMULUS. MONITORING OR RECORDING FORM SYSTEMS OTHER THAN THE LIFEPAK 10 DEFIBRILLATOR/MONITOR MAY BE DIFFICULT DUE TO THE LARGE OFFSETS PRODUCED BY PACING CURRENTS.

 

THE FOLLOWING INFORMATION MAY BE USEFUL IN OBTAINING THE BEST ECG DISPLAY POSSIBLE.

 

 

 

 

 

ABOUT QUIK-PACE ELECTRODES

 

PACING ELECTRODES ARE AN IMPORTANT PART OF THE PACING SYSTEM. THEY ARE CONSTRUCTED OF MATERIALS SPECIFICALLY DESIGNED TO PRODUCE UNIFORM CURRENT DENSITY AND MINIMIZE PATIENT DISCOMFORT.

 

PACING ELECTRODES PAR DESIGNED FOR PATIENTS WEIGHING MORE THAN 15 KG (33 LBS).

 

MAKE SURE PACING ELECTRODES: 1) FIT COMPLETELY ON TORSO, 2) HAVE A MINIMUM OF 1 – 2 INCHES OF SPACE BETWEEN ELECTRODES, AND 3) DO NOT OVERLAP BONY PROMINENCES OF THE STERNUM OR SPINE.

CONSCIOUS PATIENTS MAY EXPERIENCE DISCOMFORT DURING PACING. SEDATION AND/OR ANALGESIA MAY BE NEEDED PRIOR TO PACING.

 

PLACEMENT OF PACING ELECTRODES AFFECTS CURRENT THRESHOLD AND MAY AFFECT PATIENT COMFORT. AVOID PLACING THE NEGATIVE ELECTRODE IN THE POSTERIOR POSITION OR AT THE RIGHT UPPER ANTERIOR CHEST, AS THIS MAY CAUSE A HIGHER CURRENT CAPTURE THRESHOLD AND MORE PATIENT DISCOMFORT.

 

STORE PACING ELECTRODES IN A COOL, DRY LOCATION. THEY ARE NOT STERILE, AND ARE NOT DESIGNED TO BE AUTOCLAVED OR GAS STERILIZED.

 

PACING ELECTRODE PLACEMENT

 

ANTERIOR-POSTERIOR PLACEMENT (PREFERRED)

 

THE PREFERRED PLACEMENT OF THE PACING ELECTRODES IS ANTERIOR-POSTERIOR. THIS POSITION IS LESS LIKELY TO CAUSE PECTORIAL MUSCLE STIMULATION AND DOES NOT INTERFERE WITH PLACEMENT OF DEFIBRILLATION PADDLES OR DEFIBRILLATION ELECTRODES

  1. REMOVE ALL CLOTHING FROM PATIENT’S TORSO. DO NOT PLACE ELECTRODES OVER TAPE OR BANDAGES.
  2. CLIP OR SHAVE EXCESSIVE TORSO HAIR. AVOID NICKS OR CUTS TO SKIN WHICH MAY INCREASE PATIENT DISCOMFORT.
  3. CLEAN AND DRY SKIN. BRISKLY WIPE SKIN DRY WITH TOWEL OR GUAZE TO ABRADE SKIN AND REMOVE OILS, DIRT, ETC. IF OINTMENTS ARE ON TORSO WHERE ELECTRODES WILL BE APPLIED, REMOVE WITH SOAP AND WATER. DO NOT USE ALCOHOL OR TINCTURE OF BENZOIN TO PREPARE SKIN.
  4. REMOVE PAPER COVERING FROM EACH ELECTRODE POST
  5. FIRMLY PRESS CABLE CONNECTOR ONTO ELECTRODE POST. MATCH ELECTRODE COLOR TO CABLE CONNECTOR COLOR, RED TO RED AND BLACK TO BLACK.
  6. REMOVE PROTECTIVE LINER FROM ELECTRODE.
  7. PLACE THE BLACK ANTERIOR (- ) ELECTRODE ON THE LEFT ANTERIOR TORSO, HALFWAY BETWEEN THE XIPHOID PROCESS AND THE LEFT NIPPLE AT APEX OF THE HEART. THE UPPER EDGE OF ELECTRODES SHOULD BE BELOW THE NIPPLE. THIS CORRESPONDS TO V2 – V3 ECG POSITION, REFER TO FIGURE A. AVOID PLACEMENT OVER THE NIPPLE, DIAPHRAGM OR STERNUM, IF POSSIBLE.
  8. PLACE RED POSTERIOR (+ ) ELECTRODE ON LEFT POSTERIOR TORSO BENEATH THE SCAPULA AND LATERAL TO THE SPINE AT HEART LEVEL. AVOID PLACEMENT OVER THE BONY PROMINENCES OF THE SPINE OR SCAPULA. REFER TO FIGURE A.

    9.  

    FIGURE A. ANTERIOR-POSTERIOR PACING ELECTRODE PLACEMENT

  9. FIRMLY PRESS ELECTRODE CENTER AND EDGE ONTO TORSO FOR PROPER ADHESION.
  10. REPLACE ELECTRODES AFTER 24 HOURS.

    11. IF NECESSARY, CHANGE POSITION SLIGHTLY TO AVOID PLACING ELECTRODE OVER IRRITATED SKIN.
  11. TO REMOVE ELECTRODE FROM SKIN, SLOWLY PEEL BACK FROM THE EDGE AND DISCARD.

 

 

ANTERIOR-LATERAL PLACEMENT (ALTERNATE)

 

IF ANTERIOR-POSTERIOR PLACEMENT IS CONTRAINDICATED, THE ALTERNATE ANTERIOR-LATERAL PLACEMENT MAY BE USED. FOLLOW THE STEPS FOR ANTERIOR-POSTERIOR PLACEMENT, REPLACING STEPS 7 AND 8 WITH 7A AND 8A BELOW

 

7A PLACE THE BLACK ANTERIOR (- ) ELECTRODE ON THE LEFT ANTERIOR TORSO, JUST LATERAL TO THE LEFT OF THE NIPPLE IN THE MIDAXILLARY LINE. THIS CORRESPONDS TOO V6 ECG POSITION. REFER TO FIGURE B

 

FIGURE B. ANTERIOR-ANTERIOR (LATERAL) PACING ELECTRODE PLACEMENT

 

8A PLACE THE RED POSTERIOR (+ ) ELECTRODE ON THE RIGHT ANTERIOR UPPER TORSO SUBCLAVICULAR AREA LATERAL TO THE STERNUM. REFER TO FIGURE B.

SPECIAL PLACEMENT SITUATIONS

 

PATIENTS WITH LARGE BREASTS. IT MAY BE NECESSARY TO PLACE THE BLACK ANTERIOR (- ) ELECTRODE, WHEN USING ANTERIOR – POSTERIOR PLACEMENT, CLOSER TO V2 RATHER THAN V3.

 

OBESE PATIENTS. PLACE ELECTRODES OVER A FLAT AREA IF POSSIBLE. IF FATTY ROLLS PRECLUDE GOOD ELECTRODE ADHESION, SPREAD THE TISSUE APART.

 

 

THIN PATIENTS. FOLLOW CONTOUR OF THE RIBS AND SPACES BETWEEN THE RIBS WHEN PRESSING ELECTRODES IN PLACE.

 

RESPONSE TO NONINVASIVE PACING

 

EXTERNALLY APPLIED PACING STIMULI MAY PRODUCE SKELETAL MUSCLE CONTRACTIONS. IT MAY BE NECESSARY TO SECURE TUBING, CABLES, ETC, TO PREVENT THEIR DISPLACEMENT.

 

WHEN USING NONINVASIVE PACING ON UNCONSCIOUS PATIENTS, THE PATIENT’S LEVEL OF CONSCIOUSNESS MAY IMPROVE DURING PACING. PATIENT DISCOMFORT MAY BE MINIMIZED BY ADMINISTRATION OF A SEDATIVE OR ANALGESIC OR OF THE ANTERIOR (NEGATIVE) PACING ELECTRODE TO THE V6 ELECTRODE POSITION OR TO THE EPIGASTRIC AREA. REPOSITIONING OF THE NEGATIVE PACING ELECTRODE MAY RESULT IN A LOWER CAPTURE THRESHOLD, THUS REDUCING DISCOMFORT.

 

IF PACING ELECTRODES REMAIN IN PLACE 24 HOURS, REMOVE THEM AND APPLY A NEW SET, ADJUSTING THE POSITION SLIGHTLY.

 

ASSESSING FOR CAPTURE

 

DURING PACING, THE PATIENT SHOULD NE VISUALLY MONITORED AT ALL TIMES, AND SHOULD BE ASSESSED FOR BOTH ELECTRICAL AND MECHANICAL (VENTRICULAR) CAPTURE. SKELETAL MUSCLES TWITCHING SHOULD BE EXPECTED, BUT IT IS NOT AN INDICATION OF PACING CAPTURE.

 

IT MAY BE DIFFICULT TO INTERPRET THE ECG SIGNAL WHEN PACING AT A RAPID RATE. IN SOME PATIENTS THE ECG SIGNAL MAY BE EASIER TO INTERPRET IN LEAD 1.

 

ELECTRICAL CAPTURE STIMULATED BY NONINVASIVE PACING IS EVIDENCED BY A WIDE (>120ms) ORS COMPLEX FOLLOWED BY A TALL, BROAD T-WAVE. THE QRS COMPLEX CAN BE A POSITIVE (UPWARD) OR NEGATIVE (DOWNWARD) DEFLECTION. IN EITHER CASE, THE MOST DISTINCTIVE EVIDENCE OF ELECTRICAL CAPTURE IS THE PRESENCE OF A TALL BROAD T-WAVE. IT IS MUCH LIKE CAPTURE SEEN IN TEMPORARY TRANSVENOUS OR PERMANENT PACING. IN SOME PATIENTS, CAPTURE MAY BE LESS OBVIOUS, NOTED ONLY AS A CHANGE IN QRS CONFIGURATION.

 

ECG RECORDING STRIP OF ELECTRICAL CAPTURE

MECHANICAL OR VENTRICULAR CAPTURE IS EVIDENCED BY SIGNS OF IMPROVING CARDIAC OUTPUT. PALPATE FOR A CAROTID OR FEMORAL PULSE (RIGHT SIDE PREFERRED) AND CHECK COLOR AND TEMPERATURE OF SKIN. CHECK FOR IMPROVING BLOOD PRESSURE AND LEVEL OF CONSCIOUSNESS.

ECG DISTORTION DURING PACING

ECG ELECTRODES PICK UP PACING CURRENT, THEREFORE, ECG DISTORTION DURING PACING IS SOMETIMES EVIDENT. IT IS IMPORTANT TO DISTINGUISH BETWEEN ELECTRICAL CAPTURE AND ECG DISTORTION FOR PACING CURRENT TO AVOID MISINTERPRETATION.

ECG DISTORTION MAY OCCUR IMMEDIATELY FOLLOWING THE PACING STIMULUS. ECG DISTORTION MORPHOLOGY IS VARIABLE, HOWEVER, ECG DISTORTION WITHOUT ELECTRICAL CAPTURE RETURNS TO THE ECG BASELINE WITHOUT EVIDENCE OF A T-WAVE.

IF ECG DISTORTION IS SEVERE, SELECT ANOTHER LEAD OR REPOSITION ECG ELECTRODE AWAY FROM PACING ELECTRODES.

IF THE PATIENT HAS INTRINSIC QRS COMPLEXES, PACING PULSE MAY BLANK PART OR ALL OF ANY COMPLEX WHICH OCCURS WITHIN 40ms OF THE PULSE.

PACEMAKER REFRACTORY PERIOD

THE LIFEPAK 10 PACEMAKER HAS A REFRACTORY PERIOD WHICH IS A BRIEF, VARIABLE (RATE DEPENDENT) PERIOD OF TIME FOLLOWING THE PACING PULSE IN WHICH THE PACEMAKER WILL NOT SENSE ELECTRICAL ACTIVITY. THE PRESENCE OF THE REFRACTORY PERIOD ALLOWS THE SET PACING RATE TO BE MAINTAINED. INTRINSIC ACTIVITY WHICH OCCURS DURING THE PACEMAKER’S REFRACTORY PERIOD WILL NOT BE SENSED.

PACING PROCEDURES:

  1. TURN DEFIBRILLATOR/MONITOR 1 POWER SWITCH TO A POWER SOURCE.
  2. CONNECT ECG ELECTRODES TO ECG CABLES AND APPLY TO PATIENT.
  3. CONNECT PACING CABLE TO "PACE" CONNECTOR ON SIDE OF DEFIBRILLATOR/ MONITOR
  4. CONNECT PACING ELECTRODES TO PACING CABLE AND POSITION ELECTRODES ON PATIENT. MATCH ELECTRODE COLOR TO CABLE CONNECTOR COLOR, RED TO RED AND BLACK TO BLACK.
  5. PUSH "PACER". ADJACENT INDICATOR LIGHT ILLUMINATES.
  6. SELECT DESIRED PACING RATE (PACEMAKER POWERS UP AT A RATE OF 40 BPM
  7. OBSERVE CARDIOSCOPE. SENSE MARKER SHOULD APPEAR ON EACH QRS COMPLEX, IF SENSE MARKER IS NOT PRESENT ON QRS OR APPEARS ELSEWHERE, ADJUST ECG SIZE. IF THIS FAILS, SELECT ANOTHER LEAD AND READJUST ECG SIZE. IF INTRINSIC BEATS ARE NOT PRESENT, OMIT THIS STEP.
  8. WHEN THE DEVICE IS SENSING PROPERLY, ACTIVATE PACING BY PUSHING "START/STOP". ADJACENT INDICATOR FLASHES OFF AND A POSITIVE PACE MARKER SHOWS ON THE ECG DISPLAY WITH EACH DELIVERED PACING STIMULUS
  9. INCREASE CURRENT SLOWLY (CURRENT LEVEL BEGINS AT 0mA). CONSIDER USE OF SEDATION OR ANALGESIC IF PATIENT IS UNCOMFORTABLE. OBSERVE CARDIOSCOPE FOR EVIDENCE OF ELECTRICAL PACING CAPTURE. PALPATE PATIENT’S PULSE OR CHECK BLOOD PRESSURE TO ASSESS FOR PERFUSION (MECHANICAL CAPTURE).
  10. WHEN ACTIVATED, RECORDED ECG AND CODE SUMMARY RECORD DOCUMENT PACING PARAMETERS. EACH PACING STIMULUS IS MARKED WITH AN ARROW (­ ) ON THE LOWER EDGE OF ECG PAPER.
  11. TO STOP PACING, PUSH "START/STOP" AGAIN OR PUSH "PACER". ADJACENT INDICATOR LIGHT GOES OUT.
  12. TO REMOVE PACING ELECTRODES FROM SKIN, SLOWLY PEEL FROM EDGE

 

POSSIBLE CAUSES OF PACING INTERRUPTIONS:

IF THE PACING CABLE OR A PACING ELECTRODE BECOMES DETACHED DURING PACING, THE LEADS MESSAGE DISPLAYS ON THE STATUS DISPLAY ALONG WITH AN AUDIBLE ALARM. THE PACING RATE MAINTAINS ITS PRE-ALARM SETTING, HOWEVER, CURRENT RESETS TO 0mA. REATTACHING THE PACING CABLE OR PACING ELECTRODES SILENCES THE AUDIBLE ALARM. THE LEADS MESSAGE IS REMOVED AND PACING RATE IS MAINTAINED, BUT CURRENT REMAINS AT 0mA UNLESS INCREASED.

PACING THERAPY CANNOT BE INITIATED OR MAINTAINED IN PADDLES LEAD. IF PADDLES LEAD IS SELECTED WHEN CYCLED THROUGH LEADS DURING PACING, CURRENT RETURNS TO 0mA AND PACING THERAPY STOPS. IF PADDLES LEAD IS  

SELECTED AND PACING IS ATTEMPTED, THE LEADS MESSAGE DISPLAYS ACCOMPANIED BY TONES.

USE OF RADIO EQUIPMENT WHILE PACING MAY CAUSE CURRENT DELIVERY TO STOP AND SERVICE MESSAGE AND TONES TO APPEAR. THE MINIMIZE RADIO INTERFERENCE, MOVE RADIO FARTHER AWAY FROM THE DEFIBRILLATOR/MONITOR. IF UNABLE TO MOVE RADIO AWAY, REORIENT THE

RADIO. PUSH PACER TO STOP TONES AND ERASE SERVICE MESSAGE. TO REINSTATE PACING, FOLLOW PACING PROCEDURE BEGINNING WITH STEP 6.

 

DEFIBRILLATION DURING NONINVASIVE PACING

  1. APPLY DEFIBRILLATION GEL TO PADDLES.
  2. SELECT ENERGY TO BE DELIVERED WITH 2 ENERGY SELECT DIAL. DEVICE WILL NOT CHARGE IF A POSITION BETWEEN NUMBERED SETTINGS IS SELECTED.
  3. PUSH AND RELEASE 3 CHARGE ON APEX PADDLE

    4. WHEN CHARGE IS PUSHED, PACING STOPS IMMEDIATELY (PACING CONTROL SETTINGS RETURN TO 40 BPM AND 0mA), AND LIGHTS ADJACENT TO PACER AND START/STOP BUTTONS GO OUT. THE HEART RATE DISPLAY MEASURES THE PATIENT’S INTRINSIC RATE IN BEATS PER MINUTE AND THE AVAILABLE ENERGY DISPLAY CONFIRMS SELECTED ENERGY IN JOULES.

  4. FOLLOW STANDARD PADDLES DEFIBRILLATION PROCEDURE.

IT IS NOT GENERALLY NECESSARY TO REMOVE PACING ELECTRODES DURING DEFIBRILLATION SINCE POSITIONING OF STANDARD PADDLES DIFFERS FROM THAT OF PACING ELECTRODES. IF PACING ELECTRODES INTERFERE WITH PADDLE OR DEFIBRILLATION ELECTRODE PLACEMENT, REMOVE PACING ELECTRODES.

AHA-AED PROTOCOLS

 

GUIDELINES FOR CARE REVISED 3/2000

 

NOTE: PATIENT MUST BE PULSELESS AND BREATHLESS BEFORE THE APPLICATION OF THIS PROCEDURE.

 

  1. PRECAUTIONS FOR SPECIAL SITUATIONS
    1. PLACE THE PATIENT IN A SAFE ENVIRONMENT, AWAY FROM POOLED WATER OR METAL SURFACE.
    2. DO NOT PUT OVER MEDICATION PATCHES
    3. MAKE SURE NO PERSONNEL ARE IN DIREST CONTACT WITH THE PATIENT
    4. IF VENTILATING WITH A BVM VIA ENDOTRACHEAL TUBE, STEP BACK AND RELEASE THE BVM.
    5. ONCE PADS ARE APPLIED, DO NOT MOVE THE PATIENT
    6. RADIOS ARE TO BE TURNED OFF WITHIN 6 FT OF THE PATIENT
    7. AGONAL RESPIRATION’S SOMETIMES CAUSES THE AED TO DETECT ARTIFACT.
    8. SET-UP ON THE LEFT SIDE OF THE PATIENT. IF THE SCENE SETTING PERMITS.
    9. DEPENDING ON THE MODEL, ONCE THE AED IS ACTIVATED, THE OPERATOR SHOULD STATE, "I’M CLEAR, YOUR CLEAR, EVERYBODY CLEAR".
    10. RECOMMENDED PULSE CHECKS AFTER THE THIRD AND SIXTH DEFIBRILLATION.
    11. IF NO SUCCESS AFTER THE 6TH DEFIBRILLATION, CONTINUE AED INSTRUCTIONS UNTIL ACLS HELP ARRIVES
  2. PEDIATRICS
    3. •revised 12-12-03
    1. OBJECTIVE: TRY AND OBTAIN A GOOD PAST MEDICAL HISTORY
    2. •AED MUST be approved by FDA for use on children ages 1 - 8 and appropriate pads must be available.
      1. CARDIAC ARREST – SELDOM CAUSED BY V-FIB, THEREFORE AIRWAY CLEARANCE AND MAINTENANCE SHOULD TAKE PRIORITY
      2. NOT RECOMMENDED TO INFANTS OR PEDIATRICS LESS THAN 12 YEARS. OLD OR 90 LBS. EXCEPTIONS TO THIS:
        1. PEDIATRIC WITH CONGESTIVE HEART DEFECTS
        2. DRUG OVERDOSE
        3. ILLICIT DRUG USE (GLUE SNIFFING)
  3. HYPOTHERMIA
    1. CONFIRM HYPOTHERMIA

      2.  
    2. SHOCK UP TO THREE TIMES IF ADVISED BY DEFIBRILLATOR. IF SUCCESSFUL, INITIATE CPR AND BEGIN REWARMING PROCESS AND TRANSPORT. (A.H.A. GUIDELINES FOR ELECTRICAL THERAPY WITH THE HYPOTHERMIA PATIENT).
  4. TRAUMA
    1. TREAT ALL ASPECTS (AIRWAY, CONTROL BLEEDING, MAINTAIN C-SPINE), THEN APPLY AED
  5. TRAINING
    1. INITIAL CLASS
    2. CHECK-OFFS AND DRILLS EVERY •180 DAYS.
    3. RUNS REVIEWED BY CQI (MARIE BLEVINS) AND MEDICAL DIRECTOR (DR PINKSTON), AT HIS REQUEST
  6. QUALITY IMPROVEMENT
    1. RUNS REVIEWED BY CQI OFFICER FOR DOCUMENTATION AND TO EVALUATE THE SERVICE’S ALS SYSTEM.

 

 

RAY PINKSTON, MD

MEDICAL DIRECTOR