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Anteroposterior pacer pad position is better than anterolateral for transcutaneous cardiac pacing

      Abstract

      Introduction

      Transcutaneous cardiac pacing (TCP) is a lifesaving procedure for patients with certain types of unstable bradycardia. We aimed to assess the difference in the pacing thresholds between the anteroposterior (AP) and anterolateral (AL) pacer pad positions. The second aim was to characterize the severity of chest wall muscle contractions during TCP.

      Methods

      In this prospective crossover trial, we enrolled patients presenting to the electrophysiology laboratory for elective cardioversion. After successful cardioversion, sedated participants were sequentially paced in both positions. The study procedure concluded after successful capture or inability to achieve capture by 140 mA (the pacer’s maximum output) in both positions. Pacing thresholds were compared between positions, using a student’s paired t-test, assigning a value of 141 mA to any trials with non-capture.

      Results

      Forty-one patients were screened; 20 were enrolled in the study. Seven participants were excluded from the paired analysis (three were prevented from pacing in the second position at the anesthesiologist’s discretion, and 4 did not capture in either position). The study population consisted of 14 men and 6 women with a median age of 65 years. The mean pacing threshold was 33 mA lower (P = 0.001, 95% CI 20–45) in the AP (93 mA) versus the AL (126 mA) position. The median contraction severity score was 3 in the AL position versus 4 in the AP position (P = 0.005).

      Conclusions

      Placing pacer pads in the AP position requires less energy to capture. Major resuscitation guidelines may favor the AP position for TCP.
      ClinicalTrials.gov Identifier: NCT03898050 https://clinicaltrials.gov/ct2/show/NCT03898050.

      Keywords

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      References

      1. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005;112:IV1–203. doi: 10.1161/CIRCULATIONAHA.105.166550. Epub 2005 Nov 28. PMID: 16314375.

        • Lim S.
        • Teo W.
        • Anantharaman V.
        Cardiac Pacing and Implanted Defibrillation.
        in: Tintinalli J.E. Ma O. Yealy D.M. Meckler G.D. Stapczynski J. Cline D.M. Thomas S.H. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill, 2020
        • Kusumoto F.M.
        • Schoenfeld M.H.
        • Barrett C.
        • Edgerton J.R.
        • Ellenbogen K.A.
        • Gold M.R.
        • Goldschlager N.F.
        • Hamilton R.M.
        • Joglar J.A.
        • Kim R.J.
        • Lee R.
        • Marine J.E.
        • McLeod C.J.
        • Oken K.R.
        • Patton K.K.
        • Pellegrini C.N.
        • Selzman K.A.
        • Thompson A.
        • Varosy P.D.
        2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society.
        J Am Coll Cardiol. 2019; 74 (Epub 2018 Nov 6. Erratum in: J Am Coll Cardiol 2019;74(7):1014–6. PMID: 30412710): 932-987https://doi.org/10.1016/j.jacc.2018.10.04
        • Bektas F.
        • Soyuncu S.
        The efficacy of transcutaneous cardiac pacing in ED.
        Am J Emerg Med. 2016; 34: 2090-2093https://doi.org/10.1016/j.ajem.2016.07.022
        • Zoll P.M.
        • Zoll R.H.
        • Falk R.H.
        • Clinton J.E.
        • Eitel D.R.
        • Antman E.M.
        External noninvasive temporary cardiac pacing: clinical trials.
        Circulation. 1985; 71 (PMID: 3886190): 937-944https://doi.org/10.1161/01.cir.71.5.937
        • Bessman E.S.
        Emergency cardiac pacing.
        in: Roberts J.R. Hedges J.R. Clinical Procedures in Emergency Medicine. 6th ed. Saunders-Elsevier, Philadelphia2014: 277-297
        • Doukky R.
        • Bargout R.
        • Kelly R.F.
        • Calvin J.E.
        Using transcutaneous cardiac pacing to best advantage: How to ensure successful capture and avoid complications.
        J Crit Illn. 2003; 18: 219-225
        • Chapman P.D.
        • Stratbucker R.A.
        • Schlageter D.P.
        • Pruzina S.P.
        Efficacy and safety of transcutaneous low-impedance cardiac pacing in human volunteers using conventional polymeric defibrillation pads.
        Ann Emerg Med. 1992; 21 (PMID: 1443840): 1451-1453https://doi.org/10.1016/s0196-0644(05)80058-7
        • Moayedi S.
        • Patel P.
        • Brady N.
        • Witting M.
        • Dickfeld T.
        Anteroposterior pacer pad position is more likely to capture than anterolateral for transcutaneous cardiac pacing.
        Circulation. 2022; 146: 1103-1104https://doi.org/10.1161/CIRCULATIONAHA.122.060735
        • Deakin C.D.
        • Nolan J.P.
        European Resuscitation Council. European Resuscitation Council guidelines for resuscitation 2005. Section 3. Electrical therapies: automated external defibrillators, defibrillation, cardioversion and pacing.
        Resuscitation. 2005; 67 (PMID: 16321714): S25-S37https://doi.org/10.1016/j.resuscitation.2005.10.008
      2. Australian Resuscitation Council. ANZCOR guideline 11.4 – electrical therapy for adult advanced life support. 2016. Accessed March 29, 2022. https://resus.org.au/guidelines/.

        • Link M.S.
        • Atkins D.L.
        • Passman R.S.
        • Halperin H.R.
        • Samson R.A.
        • White R.D.
        • Cudnik M.T.
        • Berg M.D.
        • Kudenchuk P.J.
        • Kerber R.E.
        Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2010; 122 (Erratum. In: Circulation. 2011 Feb 15;123(6):e235 PMID: 20956222): S706-S719https://doi.org/10.1161/CIRCULATIONAHA.110.970954
      3. Philips. Non-invasive transcutaneous pacing: application note. 20 Accessed March 29, 2022. https://www.documents.philips.com/doclib/enc/fetch/577817/577869/Non-Invasive_Transcutaneous_Pacing.pdf.

      4. Boehm J. Tried and true: noninvasive transthoracic pacing. Zoll.com. Accessed March 13, 2019. https://www.zoll.com/CodeCommunicationsNewsletter/CCNLPacing/NTPCCNLfinal.pdf.

      5. Estes M. Temporary cardiac pacing. Uptodate.com. Updated March 1, 2019. Accessed March 29, 2022. https://www.uptodate.com/contents/temporary-cardiac-pacing.

        • Panescu D.
        • Webster J.G.
        • Tompkins W.J.
        • Stratbucker R.A.
        Optimisation of transcutaneous cardiac pacing by three-dimensional finite element modelling of the human thorax.
        Med Biol Eng Comput. 1995; 33 (PMID: 8558949): 769-775https://doi.org/10.1007/BF02523008