[Music] foreign welcome to another edition of the hand heavy 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 trial you should immediately begin CPR focusing on ventilation oxygenation chest compressions 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 presser 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 accompany significant systemic dysfunction and can impact overall metabolism and organ function in those cases the priorities 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 attending 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 in those patients you should sedate them using medications like accommodate 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 a 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 pre-meter two years old while the adult combo pads are used for patients age three and older now let's talk about the pacemaker settings make sure the monitor is set to a limb lead turn on the pacing function and set the rate between 80 and 100 for Pediatric patients confirm the current is defaulted to zero milliamps to confirm that the pacemaker is recognizing QRS complexes 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 5 to 10 milliamps above that pacing threshold all right let's transition to a full screen view of the life pack to delve into the details of transcutaneous pacing how it works is straightforward the electrodead minister and electrical stimulus to the heart causing cardiac depolarization followed by myocardial contraction whether you're using the life pack or the Zol both monitors are equipped to provide pacing in two modes demand and non-demand here I'll demonstrate using a life pack 15. by default once the limb leads replaced the life pack initiates pacing in demand mode what this means is that the life pack 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 the man pacing the machine maintains the same rate irrespective of what's happening with your patient during CPR non-demand mode is a 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 live pack 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 page for 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 setting 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 ephemeral pulse is not palpable for each captured and conducted beat immediately contact medical control for further instructions if ephemeral pulse is palpable assess the patient's blood pressure the capture fails to occur at the maximum milliamp setting 200 discontinued 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 sent 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 time [Music]