Temporary pacing (transcutaneous and transvenous): set-up, capture, sensing and safety
- Procedure
Temporary pacing keeps the heart rate up until the cause is treated; the nurse checks capture on the monitor and at the pulse, comfort, skin and settings.
What it is
Temporary pacing gives electrical impulses to the heart when its own rate is too slow or unreliable. Transcutaneous pacing uses pads on the chest and back; it is quick to start but painful and only a bridge. Transvenous pacing uses a wire passed through a central vein into the right ventricle; epicardial pacing uses wires placed on the heart during surgery. The nurse prepares the equipment, places the pads correctly, confirms electrical capture on the ECG and mechanical capture at a pulse, treats pain and anxiety as ordered, checks the skin, connections and settings, and knows what to do when the pacemaker fails to capture or to sense.
Indications
- Symptomatic or unstable slow heart rhythms that do not respond to drugs, such as high-grade heart block, as the medical team decides.
- A bridge to transvenous or permanent pacing.
- After heart surgery, through epicardial wires, to treat slow rhythms or keep AV timing.
Contraindications and precautions
- Transcutaneous pacing is relatively contraindicated in hypothermia, and is not useful in prolonged asystolic arrest.
- It is a temporary bridge only: thresholds rise with time, and in some patients tolerable capture cannot be achieved.
- Higher pacing thresholds are expected after chest surgery, with emphysema, pericardial effusion or positive pressure ventilation.
- Clean, dry, hair-trimmed skin under the pads; no alcohol or flammable liquids.
Equipment
- Monitor-defibrillator with pacing function and pacing pads (transcutaneous).
- Pacing box with fresh battery and connecting cables (transvenous or epicardial).
- Central venous access set and sterile barrier for transvenous insertion, as the protocol lists.
- ECG monitoring, emergency drugs and the crash cart nearby.
Step by step (and why)
- Explain the procedure and its discomfort, and give sedation and analgesia as ordered — pain and anxiety make pacing hard to tolerate.
- Trim hair, wash with soap and water and dry the skin — poor contact causes failure to capture, pain and burns.
- Place the front pad over the apex or at V3 and the back pad left of the spine behind it — no bone between the pads and the heart.
- Set the rate and mode as ordered, usually demand mode — fixed-rate pacing can fire on the T wave.
- Raise the output until each spike is followed by a wide QRS and a T wave, then set it above that threshold as ordered — this keeps capture reliable.
- Check a pulse that matches the paced rate at the right femoral or carotid artery — this proves the heart is pumping, not just firing.
- Transvenous or epicardial: check connections, battery, settings and which wire is which — loose connections are a common cause of failure.
- Check the skin under the pads often and reposition as needed — prolonged pacing can burn the skin.
- Record mode, rate, output, sensitivity, threshold and the patient's response — the next nurse needs the same baseline.
Complications
- Failure to capture: wire or pad movement, poor contact, loose connections, a low battery, effusion, ischaemia or acidosis.
- Oversensing (for example from shivering) can stop the pacemaker from firing; undersensing can fire on the T wave.
- Hiccups or coughing from diaphragm stimulation, and pain from muscle contraction.
- Skin burns under pads, especially with long pacing.
- Transvenous wire complications: misplacement, pneumothorax, pericardial effusion or tamponade.
Next step: when to call for help
- Call at once if capture is lost, the pulse does not match the paced rate, or the patient becomes hypotensive or loses consciousness.
- Call for a new arrhythmia, especially ventricular tachycardia or fibrillation, and be ready to defibrillate.
- Report rising thresholds, pain that does not settle with the ordered treatment, or skin damage under the pads.
- After transvenous insertion, report breathlessness, chest pain or falling pressure: pneumothorax or tamponade must be ruled out.
Test yourself
Think of the answer, then tap the question to see it.
How is electrical capture confirmed during transcutaneous pacing?
Each pacing spike is followed by a wide QRS with a distinct ST segment and T wave; the afterpotential after the spike is not capture.
Where is the pulse checked to confirm mechanical capture, and why?
At the right femoral or carotid artery, so that muscle twitching from the pacing current is not mistaken for a pulse.
Why is demand mode preferred to fixed-rate pacing?
Fixed-rate pacing ignores the heart's own beats and can fire on the T wave, which may trigger ventricular tachycardia or fibrillation.
Which skin care reduces pain and failure of transcutaneous pacing?
Trimming (not shaving) hair, washing with soap and water, drying the skin well and avoiding alcohol under the pads.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Using transcutaneous cardiac pacing to best advantage: How to ensure successful capture and avoid complications (Doukky R et al., J Crit Illn 2003;18(5):219-225) (Journal of Critical Illness, open access in PubMed Central, 2003); Temporary epicardial pacing after cardiac surgery (Gillham MJ, Barr TM, BJA Education 2023;23(9):337-349) (BJA Education, open access in PubMed Central, 2023); Troubleshooting Transvenous Pacemakers with Point of Care Ultrasound (POCUS) (Gohde E et al., POCUS J 2025;10(1):53-60) (POCUS Journal, open access in PubMed Central, 2025).
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Representative model, for educational purposes only.