Normal action potential of myocyte and main ion channels that play major roles in different phases of action potential. Data is temporarily unavailable. N Engl J Med. The patient appeared to have palpable pulses; however, the rhythm contractions of the patients body from the pacer shocks made this assessment difficult. Do not assess the carotid pulse to confirm mechanical capture; eletrical stiulation causes muscular jerking that may mimic the carotid pulse. [20]. Third-degree burns associated with transcutaneous pacing. Transcutaneous Pacing Flashcards | Quizlet 1. Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine High degree AV block with wide complex escape rhythm. Medtronic Academy [Internet]. Good pacing pad to skin attachment and close proximity of the pads to the heart are important factors in reducing the pacing threshold, which is the most important factor predicting discomfort and reliability of the captures. The patient's blood pressure improves slightly to 84/47 (confirmed by auscultation). For pacing readiness in the setting of AMI as follows: New left, right, or alternating bundle branch block or bifascicular block, Bradycardia with symptomatic ventricular escape rhythms. versed) Avoid placing the pads over an AICD or transdermal drug patches There is little data on optimal placement however, try to place the pads as close as possible to the PMI (point of maximal impulse) [1,2] Please try again soon. Kenny T. The nuts and bolts of cardiac pacing. Once the TPW has been positioned check stability by asking the patient to take deep 9. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Transcutaneous Pacing Page 2 of 2 8. Carrizales-Sepulveda EF, Gonzalez-Sarinana LI, Ordaz-Farias A, Vera-Pineda R, Flores-Ramirez R. Thermal burn resulting from prolonged transcutaneous pacing in a patient with complete heart block. [Internet]. Skin burns, pain, discomfort, and failure to capture are the main limitations of this method. 1. Monitor your patient's heart rate and rhythm to assess ventricular response to pacing. Zagkli F, Georgakopoulou A, Chiladakis J. The anterior electrode should have negative polarity and should be placed either over the cardiac apex or at the position of lead V3. Technique: Ideal pacer pad placement sandwiches the heart between the pacing pads and mimics the hearts normal electrical axis. Transcutaneous Cardiac Pacing. Conscious patients require analgesia for discomfort unless delay for sedation will cause/contribute to deterioration. Algorithms for loss of capture for transcutaneous and transvenous pacemakers have been developed. When bradycardia is the cause of symptoms, the rate is generally less than 50/min. Am J Emerg Med. Bradyarrythmia or bradycardia [terms are interchangeable]: Any rhythm disorder with a heart rate less than 60/min eg, third-degree AV block or sinus bradycardia. J Am Coll Cardiol. METHOD OF INSERTION AND/OR USE place pads in AP position (black on anterior chest, red on posterior chest) connect ECG leads set pacemaker to demand turn pacing rate to > 30bpm above patients intrinsic rhythm set mA to 70 start pacing and increase mA until pacing rate captured on monitor Increasing energy can assist mitigating that risk. External transcutaneous pacing has been used successfully for overdrive pacing of tachyarrhythmias; however, it is not considered beneficial in the treatment of asystole. Rosenthal E, Thomas N, Quinn E, Chamberlain D, Vincent R. Transcutaneous pacing for cardiac emergencies. However, if the threshold is > 10 mA, the margin of safety is set to a lesser value, so as not to accelerate fibrosis at the lead/myocardium interface. Video courtesy of Therese Canares, MD; Marleny Franco, MD; and Jonathan Valente, MD (Rhode Island Hospital, Brown University). Assess his hemodynamic response to pacing by assessing his central pulses (see Cautions for using TCP) and taking blood pressure (BP) on both arms. Ali A Sovari, MD, FACP, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Physician Scientists Association, American Physiological Society, Biophysical Society, Heart Rhythm Society, Society for Cardiovascular Magnetic ResonanceDisclosure: Nothing to disclose. In contrast, true electrical capture will show wide QRS complexes with tall, broad T-waves. 2007 Sep. 74(3):559-62. Our editorial team follows strict sourcing guidelines and relies on academic research institutions, government agencies, medical associations, and peer-reviewed medical literature in the field of resuscitation and emergency medical care. Available from: http://www.medtronicacademy.com/. All rights reserved. At ACLS Medical Training, we pride ourselves on the quality, research, and transparency we put into our content. Leong D, Sovari AA, Ehdaie A, et al. (eds) Interventional Critical Care. Transcutaneous pacing (TCP) is a difficult skill that is often performed incorrectly. drop in blood pressure on standing (orthostatic hypotension), pulmonary congestion on physical exam or chest x-ray, bradycardia-related (escape) frequent premature ventricular complexes or VT, Present by definition, ie, heart rate less than 50/min. Step 3: Set the demand rate to approximately 60/min. Google Scholar. Crit Care Nurse. 2008 May 27. [QxMD MEDLINE Link]. This rate can be adjusted up or down (based on patient clinical response) once pacing is established. Accessed: October 28, 2021. Source: Reprinted from How to provide transcutaneous pacing, Nursing2005, K Craig, October 2005. threshold to provide a safety margin. How to provide transcutaneous pacing. Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty ProfessorsDisclosure: Nothing to disclose. Some error has occurred while processing your request. Ettin DCook T. Using ultrasound to determine external pacer capture. Your 10% OFF discount codehas been sent to your email. Please try after some time. You must decide if the patient has adequate or poor perfusion: If the patient has poor perfusion secondary to bradycardia the treatment sequence is as follows: Technique: Perform Transcutaneous Pacing are as follows: Most patients will improve with a rate of 60 to 70/min if the symptoms, Online Resources For Primary Care Physicians, 2018 ACLS Review The Tachycardia Algorithm Part 5 From The ACLS Manual, Reviewing Episode 13 Part 2: Killer Coma Cases The Intoxicated Patient From Emergency MedicineCases, Reviewing Episode 13 Part 1: Killer Coma Cases The Found Down Patient From Emergency Medicine Cases, The Best Way to Start a Podcast PCI 333 From Blubrrys Pod, Sturge Weber Syndrome Podcast From PedsCases With A Link To An Additional Resource, Neurofibromatosis Type 1 (NF1) From PedsCases With Links To Additional Resources, Approach To Childhood Glaucoma Podcast From PedsCases, Reviewing Episode 33: Oncologic Emergencies From Emergency Medicine Cases, Linking To The Referring Physician Imaging Ordering Guide: What to Order When From Radia, Oncologic Emergencies (Part2) From EMC Rapid Review Videos, Oncologic Emergencies (Part 1) From EMC Rapid Review Videos, Postmenopausal Bleeding From StatPearls, Anaphylaxis and Anaphylactic Shock From Emergency Medicine Cases, #382 Abnormal Uterine Bleeding From The Curbsiders With Links To Additional Resources, False negative point-of-care urine pregnancy tests in an urban academic emergency department: a retrospective cohort study-Links And-Excerpts, Links To A Minicourse On Subarachnoid Hemorrhage By Dr. Chris Nickson From Life In The Fast Lane, Coma-like Syndromes By Dr. Chris Nickson From Life In The Fast Lane, Best Case Ever 22: Nonconvulsive Status Epilepticus (NCSE) From Emergency Medicine Cases, Non-Convulsive Status Epilepticus From EM Quick Hits, Link And Excerpts From Long QT From StatPearls With An Additional Resource And A Caveat, Genetic Diseases 3: Genetic testing technologies From Pedscases, Genetic Diseases 2: X-linked inheritance From PedsCases, Link To And Excerpts From Syncope From StatPearls, Genetic Diseases 1: Autosomal dominant inheritance From PedsCases With A Link To A Resource On Long QT Syndrome, Two Lists From The New York Times: 50 Best Netflix Films Now And 50 Best Netflix TV Series Now, Links To Stanford Medicine 25s 10 Video Introduction To Ultrasound Series (Point of Care, POCUS), Common Mistakes in Point of Care Cardiac Ultrasound (Echocardiography, POCUS) From Stanford Medicine 25, Point of Care Cardiac Ultrasound (Echocardiography, POCUS) From Stanford Medicine 25, Basic cardiac POCUS: image acquisition-A Teaching Video From UBC IM POCUS, Link To Complete List Of ACOG Guidelines With Links To Some Examples, Autonomic Failure & Orthostatic Hypotension From Dysautonomia International, Differentiate between signs and symptoms that are caused by the slow rate versus those that are unrelated, Correctly diagnose the presence and type of AV block, Use atropine as the drug intervention of first choice, Decide when to initiate transcutaneous pacing (TCP), Decide when to start epinephrine or dopamine to maintain heart rate and blood pressure. A discussion of transcutaneous pacing and indications for the prophylactic placement of a transvenous pacemaker has been included. By continuously monitoring his cardiac rate and rhythm and delivering pacing impulses through his skin and chest wall muscles as needed, TCP causes electrical depolarization and subsequent cardiac contraction to maintain cardiac output. If you log out, you will be required to enter your username and password the next time you visit. Circulation - Pacing (transcutaneous) | Emergency Care Institute Transcutaneous pacing can be painful and may fail to produce effective mechanical capture. Pacing Clin Electrophysiol. https://doi.org/10.1007/978-3-030-64661-5_18, DOI: https://doi.org/10.1007/978-3-030-64661-5_18. Perform, but do not rely on a pulse check! 2007. To improve patient outcomes by identifying and treating early clinical deterioration To provide online consultation to emergency medical services personnel in the field To improve patient outcomes by identifying and treating early clinical deterioration What happens when teams rapidly assess and intervene when patients have abnormal vital signs? OpenAnesthesia content is intended for educational purposes only. Most patients cannot tolerate currents of 50 milliamps and higher without sedation. Reuse of OpenAnesthesia content for commercial purposes of any kind is prohibited. These heart contractions did not correspond with the surrounding thoracic muscle contractions generated by the pacer. Do not be fooled by skeletal muscle contraction! [QxMD MEDLINE Link]. The equipment shown is courtesy of Zoll Medical Corp. You may be trying to access this site from a secured browser on the server. 51"Hbl~"8qXn5FSD Treat underlying cause. Oesophageal and transcutaneous pacing may depolarise large areas of the myocardium simultaneously, but the effect is usually similar to ventricular pacing. 60/min and milliamps to 0, Increase mA until electrical capture is obtained, Check to ensure the patient has mechanical capture ( Do not asses the carotid pulse for confirmation; electrical stimulation causes muscle jerking that may mimic the carotid pulse), Set the output 2 mA above the dose at which consistent mechanical capture is observed as a safety margin, reassess the patient to confirm if they are now hemodynamically stable ( increase rate as needed), reassess the patient to determine id sedation is now needed ( if not already administered), Advanced Airway - Endotracheal Intubation, Bio Chapter 20 pre lecture : Evolution of lif. D Conduct a problem-focused history and physical examination; search for and treat possible contributing factors. Simply email us through the contact us link displayed on every page of this website any time within 60 days of purchase. J Pacing Clin Electrophysiol. Transcutaneous pacing with external pacemakers is indicated as a temporizing measure for treatment of symptomatic bradycardias, including sinus bradycardias and atrioventricular (AV) nodal blocks; it may also be used prophylactically in patients with these rhythms who are maintaining a stable blood pressure. Philadelphia: Elsevier; 2019. p. 45660. 1999;17:10071009. These modifications allow administration of higher currents with less patient discomfort. Three common causes of bradycardia in the emergency department include drugs (specifically overdoses) hyperkalemia, and myocardial ischemia: While most textbooks may quote overdrive pacing for refractory tachyarrhythmias, practically speaking, most of these will get simply get cardioverted, TCP is only a bridge until a transvenous pacemaker can be placed, There are a few instances where TCP may be preferable over TVP, Patients who may respond to respond to therapy (eg. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 11921. Target rate is generally 60-80 bpm. The problem of false capture (also known as echo distortion) is under-recognized and under-reported in the medical literature. Pacing Clin Electrophysiol. Transcutaneous pacing electrodes (self adhesive gel pads frequently also used as defibrillator pads) are usually positioned in an anteroposterior configuration (see Fig. In addition to synchronized TCP, there is an option for asynchronous TCP in cases of VF, VT, complete heart block. Capture achieved at 140 mA and confirmed with sudden rise in ETCO2 (ems12lead.com). 309(19):1166-8. Pacing spikes are visible with what appear to be large, corresponding QRS complexes. stream Those units can usually deliver a current as high as 200 mA for as long as 40 ms. B, No skeletal muscle contraction/movement occurred while pacing with the extracardiac lead at 2.7 V. This is supported by the unchanging accelerometer signals before and after pacing is delivered. When considering institution of transcutaneous pacing, always think about alternate causes for acute dysrhythmia, e.g. Learn how temporary noninvasive cardiac pacing can protect your patient until normal conduction is restored or he receives a transvenous pacemaker. EMS is dispatched to a private residence for 70-year-old female who is believed to be unconscious. Ramin Assadi, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, Society for Cardiovascular Angiography and InterventionsDisclosure: Nothing to disclose. % 71(5):937-44. Get new journal Tables of Contents sent right to your email inbox, Take the lead on safety with temporary cardiac pacing, Monitoring temporary pacemaker connections, Articles in PubMed by Karen Craig, RN, BS, Articles in Google Scholar by Karen Craig, RN, BS, Other articles in this journal by Karen Craig, RN, BS, Privacy Policy (Updated December 15, 2022). [QxMD MEDLINE Link]. Before applying the pacing electrodes, wipe the patients skin with alcohol, and allow the area to dry. The posterior electrode, which should be of positive polarity, should be placed inferior to the scapula or between the right or left scapula and the spine; it should not be placed over the scapula or the spine. Strongly consider sedation, as external pacing can be quite uncomfortable. may email you for journal alerts and information, but is committed 309(19):1166-8. She is sent to the cardiac cath lab where a permanent pacemaker is placed. In the ICU the patient remains dangerously hypotensive in spite of dobutamine and levophed drips. The size of the electrode pads usually ranges from 8-15 cm, and the pacing electrodes can be applied by medical personnel. x.,]+7%0:g&qET 8ix5?o eZ/Qn>HeyMn60mnGjhZ,w9_-N>nwd1Yh`TTv\5|Z 4=!vC x kuQ Pacing Clin Electrophysiol. [PMID:8558949], 3. Questions or feedback? Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a systematic review. Step 4: Set the current milliamperes output 2 mA above the dose at which consistent capture is observed (safety margin). [Full Text]. [QxMD MEDLINE Link]. Chest. 7 Steps to Calculate the Magin of Safety. Temporary cardiac pacing | Pacemakers and ICDs | Oxford Academic %PDF-1.7 % Assessment of capture (typically between 50-90 mA): look at the ECG tracing on the monitor for pacer spikes that are each followed by a QRS complex. Part 7.3: Management of Symptomatic Bradycardia and Tachycardia Q Sinus bradycardia may have many causes. How to Calculate Warren Buffett's Margin of Safety: Formula + Excel [21]. Schwartz B, Vermeulen MJ, Idestrup C, Datta P. Clinical variables associated with mortality in out-of-hospital patients with hemodynamically significant bradycardia. Pacing Clin Electrophysiol. If cardiovascular symptoms are not caused by the bradycardia, the patient may not improve despite effective pacing. 2018 Jun. The. Many medical comorbidities and medications may affect the hearts conduction system and cause significant changes in heart rate and thus cardiac output. Avoid using your patient's carotid pulse to confirm mechanical capture because electrical stimulation can cause jerky muscle contractions that you might confuse with carotid pulsations. muscle artifact). Our website services, content, and products are for informational purposes only. It is safe to touch patients (e.g. 2004;24(3):2532. Critical care medicine, principles of diagnosis and management in the adult. Philadelphia: Elsevier; 2019. p. 5071. Alternatively, the positive electrode can be placed anteriorly on the right upper part of the chest (see the image below). [QxMD MEDLINE Link]. Sodeck GH, Domanovits H, Meron G, et al. However, she is still non-verbal and does not follow commands. Skeletal muscle contraction occurs at current levels as low as 10 milliamps, and does NOT suggest electrical or mechanical capture. Am J Emerg Med 2016; 34:2090. Position the electrodes on clean, dry skin and set the pacing current output as shown in the photos. Pulses are difficult to palpate due to excessive muscular response. Document your patient's initial cardiac rhythm (including rhythm strip and 12-lead ECG if possible), the signs and symptoms that indicated his need for pacing therapy, the pacer settings (rate, current output, pacing mode), a cardiac rhythm strip showing electrical capture, the patient's pulse and BP, his pain intensity rating, analgesia or sedation provided, and his response. Med Biol Eng Comput. Acute myocardial infarction complicated by ventricular standstill terminated by thrombolysis and transcutaneous pacing. N Engl J Med. Share cases and questions with Physicians on Medscape consult. Holger JS, Minnigan HJ, Lamon RP, Gornick CC. Malden: Blackwell Publishing; 2005. 2006 Aug. 70(2):193-200. Know when to call for expert consultation about complicated rhythm interpretation, drugs, or management decisions. Note that pacing temporary wires at unnecessarily high outputs may lead to premature carbonisation of the leads and degradation of wire function. If still no ventricular capture is achieved further attempts to reposition the TPW should be made. Then calculate the NPV of these cash flows by dividing it by the discount rate. Sign up with your email address to receive updates and new posts. Often 50-100 mA are required. [Guideline] Glikson M, Nielsen JC, Kronborg MB, et al, for the ESC Scientific Document Group . Patients requiring a permanent system should only undergo temporary pacing for syncope at rest, haemodynamic compromise, or bradycardia-induced ventricular tachyarrhythmias. Studies have demonstrated that more than 90% of patients tolerate pacing for 15 or more minutes. 2008 Feb. 15(1):110-6. endstream endobj startxref [cited 2019 July 22]. 1999 Apr. Ettin D, Cook T. Using ultrasound to determine external pacer capture. PubMedGoogle Scholar. Sovari A, Zarghamravanbakhsh P, Shehata M. Temporary cardiac pacing. trauma, hypoxia, drug overdose, electrolyte imbalances and hypothermia. It is accomplished by delivering pulses of electric current through the patients chest, stimulating the heart to contract. If capture is maintained but the patient remains symptomatic of inadequate tissue . [QxMD MEDLINE Link]. The adult pads are placed and transcutaneous pacing is initiated. Answer: During transcutaneous pacing procedure, upon electrical and mechanical capture, it is recommended to increase the milliamps (mA) 10% higher than the threshold of initial electrical capture as a safety margin (usually 5-10 mA). m+W2=`q4blz{e3TM^|fs|Tr?K=oH oHx}|>$z~Wy\>C,vV32 ].CuZ1p>p4Z:a{{YrrxNu6b$@I75>$OE}%y9^d`T[EtED13|KZZ:] " Bernstein AD, Daubert JC, Fletcher RD, Hayes DL, Luderitz B, Reynolds DW, Schoenfeld MH, Sutton R. The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. 2019;155(4):74957. hyperkalemia, drug overdose), Avoid placing the pads over an AICD or transdermal drug patches, There is little data on optimal placement however, try to place the pads as close as possible to the PMI (point of maximal impulse) [1,2]. What is the safety margin for a transcutaneous pacemaker? The most common indication for TCP is symptomatic bradycardia, most commonly resulting from acute MI, sinus node dysfunction, and complete heart block. This rate can be adjusted up or down (based on patient clinical response) once pacing is established. Brooks M. ESC Updates guidance on cardiac pacing, resynchronization therapy. TCP is contraindicated in severe hypothermia and is not recommended for asystole. 22(4 Pt 1):588-93. ATRIAL THRESHOLD Insert the transcutaneous pacing wire. [QxMD MEDLINE Link]. External transcutaneous pacing has been used successfully for overdrive pacing of tachyarrhythmias; however, it is not considered beneficial in the treatment of asystole. Houmsse M, Karki R, Gabriels J, et al. The utility of ultrasound to determine ventricular capture in external cardiac pacing. Europace. [QxMD MEDLINE Link]. Heart rate is determined by the bodys physical needs (via nervous system input) and is usually controlled by the sinus node. Transcutaneous pacing - OpenAnesthesia hemodynamically unstable bradycardias that are unresponsive to atropine, bradycardia with symptomatic escape rhythms that don't respond to medication, cardiac arrest with profound bradycardia (if used early), pulseless electrical activity due to drug overdose, acidosis, or electrolyte abnormalities. 9% normal saline is run wide open with an additional IV line established in the left lower extremity. Capture achieved at 110 mA confirmed with SpO2 plethysmograph, Pacing Artifact May Masquerade As Capture. Permanent-temporary pacemakers in the management of patients with conduction abnormalities after transcatheter aortic valve replacement. If the positive electrode is placed anteriorly, the pacing threshold may increase significantly; this, in turn, increases the patients discomfort and may result in failure to capture. PKQb< k(E=$@[iAK2)^a0}u&+IDWdbI&r Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. The margin of safety formula can also be applied to different departments within a single company to define how risky they may be. Provided by the Springer Nature SharedIt content-sharing initiative, Over 10 million scientific documents at your fingertips, Not logged in A rhythm strip showing failure to capture in the first four pacing stimuli that did not produce any pulse. Recognition of a symptomatic bradycardia due to AV block is a primary goal. Trigano AJ, Azoulay A, Rochdi M, Campillo A. Electromagnetic interference of external pacemakers by walkie-talkies and digital cellular phones: experimental study. [QxMD MEDLINE Link]. In this case, you have a patient presenting with symptoms of bradycardia. A medical history is obtained from family members and includes heart failure, stroke, and hypertension. Europace. Know that the patient may become more alert whether capture is achieved or not. [QxMD MEDLINE Link]. Castle N, Porter C, Thompson B. Hemodynamic responses to noninvasive external cardiac pacing. He may require TCP until his conduction system recovers or until he receives a transvenous pacemaker. 1983 Nov 10. If capture occurs, slowly decrease output until capture is lost (threshold) then add 2 mA or 10% more than the threshold as a safety margin. 1988 Dec. 11(12):2160-7. Utility and safety of temporary pacing using active fixation leads and externalized re-usable permanent pacemakers after lead extraction. PDF Trancutaneous Pacing Resuscitation. [QxMD MEDLINE Link]. 14(2):137-42. The pacing electrode pads of an external pacing unit and locations in which each pad should be placed. Five Step Approach to Transcutaneous Pacing Step 1: Apply the pacing electrodes and consider sedation (eg. EKG- Transcutaneous Pacing Flashcards | Quizlet 148 0 obj <>/Filter/FlateDecode/ID[<080B985F646C544C9743A9819668209B>]/Index[124 45]/Info 123 0 R/Length 115/Prev 507343/Root 125 0 R/Size 169/Type/XRef/W[1 3 1]>>stream Ali A Sovari, MD, FACP, FACC Attending Physician, Cardiac Electrophysiologist, Cedars Sinai Medical Center and St John's Regional Medical Center [QxMD MEDLINE Link]. Although transcutaneous pacing has been used continuously for as long as 4-5 days, [22, 23] the sites at which the pads are applied should be changed every 4-5 hours to reduce skin burn and discomfort. Sherbino J, Verbeek PR, MacDonald RD, Sawadsky BV, McDonald AC, Morrison LJ. Add 2 mA or set the output 10% higher than the threshold of initial electrical capture as a safety margin. Transcutaneous Cardiac Pacing. The temporary pacing wire or epicardial (post-surgical) wires are . Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA, Department of Surgery, Oregon Health & Science University, Portland, OR, USA, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA, Allshouse, K.J., Musialowski, R.S. Expose the patients torso, turn on monitor and apply leads, Confirm bradyarrhythmia and signs and symptoms indicating TCP, Attach Defib pads on torso as recommended by manufacturer anterior/posterior, Explain. [PMID:12811719]. 2020 Dec. 31(12):3277-85. Transcutaneous Cardiac Pacing Technique: Transcutaneous Pacing - Medscape 2002;25(2):2604. 19(2):134-6. [Guideline] Epstein AE, DiMarco JP, Ellenbogen KA, et al. Transvenous Pacing - an overview | ScienceDirect Topics 2008;117:282040. [QxMD MEDLINE Link]. Modern external pacemakers use longer pulse durations and larger electrodes than the early models did. This case will focus on the patient with a bradycardia and a heart rate less than 50/min. Ramin Assadi, MD Assistant Professor of Medicine, Division of Interventional Cardiology, University of California, Los Angeles, David Geffen School of Medicine
