Page 223 - 2026 SMOG

TRANSCUTANEOUS (EXTERNAL) CARDIAC PACING
Clinical Indications
• Patients with pulse rate <60 (or appropriate for age) and signs of inadequate cerebral or
endorgan perfusion
Contraindications
• None
Procedure
• Severe hypothermia—focus on active rewarming and resuscitation first; wait at least 1 minute
to feel pulse during rewarming (Follow Cold Weather Injury Protocol)
• Ensure the patient is attached to a monitor and defibrillator with external cardiac pacing
capabilities.
• Time-permitting, ensure adequate IV/IO access prior to pacing. Also, may consider sedation
(Midazolam 0.5–2mg q5min) prior to beginning pacing.
• Turn the selector switch to “Pace”
• Set rate to twice the patient’s intrinsic rate (often 70–80 for adults, 100 for pediatric)
• Set energy level to the lowest setting and gradually increase until capture is obtained (each
pacer spike followed by QRS)
• Once capture is obtained, ensure pulse and vital signs correspond with pacing. Evaluate the
patient for improvement. Monitor and continue sedation as needed
• If it fails to capture at the maximal setting, discontinue the pacer
• At any time, if the patient degenerates and needs CPR, begin compressions immediately. Pacer
pads are insulated, and it is okay to perform compressions with the pacer running
**Document procedure, results, and vital signs.**

2026 Standard Medical Operating Guidelines (SMOG) • 215