Pediatric Transcutaneous Pacing

Introduction

• Transcutaneous pacing is a life-saving procedure for pediatric patients with severe bradycardia or heart block.
• Suitable for situations where other interventions like CPR and medications do not improve the condition.

Indications

• Pediatric patients with altered mental status and bradycardia caused by complete heart block or sinus node dysfunction.
• Begin CPR focusing on:
  • Ventilation
  • Oxygenation
  • Chest compressions
  • Medications
• If interventions fail, consider pacing.
• AHA recommends cardiac arrest dose of epinephrine for symptomatic bradycardia.

Contraindications

• Severe hypothermia
• Asystolic cardiac arrest
• Focus should be on treating underlying hypothermia.

Procedure

Patient Assessment

• Typically for children actively receiving CPR.
• Sedation and pain management are unnecessary in CPR scenarios.
• For conscious patients:
  • Use medications like accommodate, midazolam, fentanyl, morphine, or ketamine.

Monitoring Setup

• Ensure a patent and secure airway.
• 4-lead cardiac monitoring is crucial.
• Apply combo pads:
  • Anterior-posterior placement is preferred.
  • Anterior-lateral placement as an alternative.
• Pediatric combo pads for ages pre-mature to 2 years.
• Adult combo pads for ages 3 and older.

Pacemaker Settings

• Monitor should be set to a limb lead.
• Set pacing function rate between 80-100 for children.
• Default current is zero milliamps initially.
• Increase amperage in 10 milliamp increments until electrical capture occurs (Pacer Spike followed by a wide QRS complex).
• Set the final output 5-10 milliamps above the pacing threshold.

Pacing Modes

Demand Mode

• Stops pacing when patient’s rate surpasses the set rate.

Non-Demand Mode

• Consistent rate of impulses regardless of patient's rhythm.
• Better choice during CPR as chest compressions interfere with ECG.

Monitoring and Transition

• Check for mechanical capture by assessing the patient's pulse.
• Contact medical control if capture fails.
• In case of pulse loss, start CPR immediately.
• Transfer procedures to hospital staff include setting new pads and limb leads.

Conclusion

• Transcutaneous pacing in Pediatrics is critical and requires following steps for effective intervention.
• Expertise and quick actions make a significant difference in patient outcomes.

Acknowledgments

• Dr. Mike Levy for his presentation on this topic.