[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical skills](https://durgical.com/en/clinical-skills/) › [Airway and cardiac procedures](https://durgical.com/en/clinical-skills/areas/airway-cardiac/) › Transcutaneous pacing

# Transcutaneous pacing

- Procedure

Pads on the chest send regular electrical pulses that make a very slow heart beat at a safe rate, as a bridge to a definitive pacemaker.

Updated Nov 13, 2026

## Key points

- For unstable bradycardia not responding to atropine, or where atropine will not work (Mobitz II, complete heart block with broad complexes).
- Increase the current until electrical capture: each spike followed by a broad QRS and T wave.
- Confirm mechanical capture with a femoral pulse or pulse oximetry trace, not the carotid (muscle twitch misleads).
- Pacing hurts: give analgesia and sedation to a conscious patient.
- A bridge only: arrange transvenous or permanent pacing and treat the cause.

On this page

- The basics Key points
- What it is
- Indications
- Equipment
- Step by step (and why)
- Next step
- Elsewhere in DurgiPedia

- Clinical Complications

- Safety Contraindications and precautions

- Study Test yourself

- Connections Connections

## What it is

Transcutaneous (external) pacing delivers repeated electrical pulses through large adhesive pads on the chest wall to depolarise the ventricles at a set rate. It is a temporary, non-invasive measure for haemodynamically unstable bradycardia that does not respond to atropine or other drugs, or in which atropine is unlikely to work, such as Mobitz type II or complete heart block with broad escape complexes, or a transplanted heart. It buys time until transvenous pacing or a permanent pacemaker is arranged, and while the cause is treated (ischaemia, hyperkalaemia, drug toxicity). Pads are usually placed anteroposterior, with the anterior pad over the cardiac apex area left of the sternum and the posterior pad between the left scapula and the spine, or in the anterolateral position. The device is set in demand mode, a rate is chosen, and the current is increased from low until every pacing spike is followed by a broad QRS complex (electrical capture). Electrical capture is not enough: the operator must confirm mechanical capture, a palpable pulse matching the paced rate, best felt at the femoral artery because chest-muscle twitching makes carotid palpation misleading. The current is then set a margin above the threshold, as the device and protocol set. Pacing is painful, so a conscious patient needs analgesia and sedation, and the arrangement is reassessed often because capture can be lost.

## Indications

- Symptomatic bradycardia with adverse features (shock, syncope, ischaemia, heart failure) despite atropine.
- High-risk bradyarrhythmias: Mobitz type II, complete heart block with broad QRS, ventricular pauses.
- Bradycardia from drug toxicity (beta-blocker, calcium-channel blocker, digoxin) while specific treatment starts.
- Bridge to transvenous pacing or a permanent pacemaker.
- P-wave asystole (atrial activity with no ventricular response) in a peri-arrest setting.

## Contraindications and precautions

- Asystole without P waves: pacing is not effective; continue CPR and treat causes.
- Severe hypothermia: bradycardia may be physiological and the heart is irritable; rewarming comes first.
- Conscious patient: pain and distress; plan analgesia and sedation before increasing the current.
- Wounds, burns or an implanted device at the pad sites: move the pads.
- Stable patient: pacing is not needed; monitor and treat the cause, with pads applied in case of deterioration.

## Equipment

- Defibrillator-monitor with a pacing function and ECG leads connected to it.
- Pacing-defibrillation pads (multifunction), razor and towel.
- Monitoring: blood pressure, pulse oximetry and continuous ECG.
- Analgesic and sedative drugs, airway equipment and resuscitation drugs (atropine and others the protocol lists).
- Plan for transvenous pacing: central venous access kit and fluoroscopy or ultrasound.

## Step by step (and why)

- Assess ABCDE, confirm unstable bradycardia and give atropine as protocol sets — pacing follows if this fails or will not work.
- Explain, consent if possible, and give analgesia and sedation — the current causes painful muscle contraction.
- Attach ECG leads to the device and place pads anteroposterior or anterolateral on dry skin — the device senses through the leads.
- Select demand mode and set the rate as protocol sets — demand mode avoids pacing on top of the patient's own beats.
- Increase the current gradually until each spike is followed by a broad QRS — this is electrical capture.
- Feel the femoral pulse or watch the oximetry trace matching the paced rate — this is mechanical capture.
- Set the current a margin above the capture threshold, as the device sets — capture can be lost as conditions change.
- Reassess capture, pain, skin and blood pressure often, and call for definitive pacing — this is a bridge, not a treatment.
- Document rate, current, capture and the time pacing began — the next team needs these settings.

## Complications

- Pain and discomfort from skeletal muscle stimulation.
- Skin burns under the pads, especially with prolonged pacing.
- Failure to capture (obesity, emphysema, effusion, poor pad position), sometimes not recognised.
- Pacing artefact hiding an underlying ventricular fibrillation; muscle twitching mistaken for a pulse.
- Rarely, induction of arrhythmias.

## Next step

- Call a senior and cardiology early for transvenous pacing or a permanent pacemaker.
- Look for and treat the cause: 12-lead ECG for ischaemia, potassium and other electrolytes, drug levels and a drug history.
- Specific treatment of the cause while pacing (for example, of hyperkalaemia or of beta-blocker or calcium-channel blocker toxicity).
- Keep continuous monitoring in a high-dependency area, with the defibrillator ready.
- Check the skin under the pads and the patient's comfort regularly; change pads as the device instructions set.

## Test yourself

Think of the answer, then tap the question to see it.

## What are the indications for transcutaneous pacing?

Unstable bradycardia that does not respond to atropine, or in which atropine is unlikely to work (Mobitz II, complete heart block with broad complexes), as a bridge to definitive pacing.

## What is the difference between electrical and mechanical capture?

Electrical capture is a broad QRS after each pacing spike on the monitor; mechanical capture is a palpable pulse at the paced rate, showing the ventricles actually contract.

## Why is the femoral pulse preferred to the carotid to check mechanical capture?

Pacing makes the chest and neck muscles twitch, which can be mistaken for a carotid pulse; the femoral pulse or oximetry trace is more reliable.

## Why is transcutaneous pacing not used in asystole without P waves?

There is no evidence of benefit; the heart does not respond, so CPR and treatment of reversible causes continue instead.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-skills/transcutaneous-pacing/)

## Elsewhere in DurgiPedia

- [The cardiac conduction system](https://durgical.com/en/physiology/the-cardiac-conduction-system/)
- [The SA node pacemaker potential](https://durgical.com/en/physiology/the-sa-node-pacemaker-potential/)
- [Cardiac monitoring at the bedside: leads, alarms and rhythm changes to report](https://durgical.com/en/nursing/cardiac-monitoring-at-the-bedside-leads-alarms-and-rhythm-changes-to-report/)

## Connections

## Related 6

- [AV blocks: first, second (Mobitz I and II) and third degree](https://durgical.com/en/clinical-skills/av-blocks-first-second-and-third-degree/)
- [Paced rhythms](https://durgical.com/en/clinical-skills/paced-rhythms/)
- [Hyperkalaemia and other electrolyte changes](https://durgical.com/en/clinical-skills/hyperkalaemia-and-other-electrolyte-changes/)
- [Defibrillation and synchronised cardioversion](https://durgical.com/en/clinical-skills/defibrillation-and-synchronised-cardioversion/)
- [Central venous catheter: sites, Seldinger technique and checks](https://durgical.com/en/clinical-skills/central-venous-catheter-sites-seldinger-technique-and-checks/)
- [The emergency (ABCDE) station](https://durgical.com/en/clinical-skills/the-emergency-station/)

## Related conditions 6

- [Atrioventricular (heart) block](https://durgical.com/en/conditions/atrioventricular-block/)
- [Sinus node dysfunction (sick sinus syndrome) and symptomatic bradycardia](https://durgical.com/en/conditions/sinus-node-dysfunction-and-symptomatic-bradycardia/)
- [Myocardial Infarction (Heart Attack)](https://durgical.com/en/conditions/myocardial-infarction/)
- [Beta-blocker and calcium-channel-blocker overdose](https://durgical.com/en/conditions/beta-blocker-and-calcium-channel-blocker-overdose/)
- [Digoxin toxicity](https://durgical.com/en/conditions/digoxin-toxicity/)
- [Hyperkalaemia](https://durgical.com/en/conditions/hyperkalaemia/)

## In Pharmacology 5

- [Atropine](https://durgical.com/en/pharmacology/atropine/)
- [Isoprenaline](https://durgical.com/en/pharmacology/isoprenaline/)
- [Epinephrine](https://durgical.com/en/pharmacology/epinephrine/)
- [Opioids and antagonists](https://durgical.com/en/pharmacology/classes/opioids-and-antagonists/)
- [Midazolam](https://durgical.com/en/pharmacology/midazolam/)

[← All clinical skills](https://durgical.com/en/clinical-skills/)

Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: [Transcutaneous Pacing](https://www.ncbi.nlm.nih.gov/books/NBK519567/) (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/clinical-skills/transcutaneous-pacing/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-skills/transcutaneous-pacing/