Pediatric Transcutaneous Pacing

Symptomatic bradycardia in the pediatric population is most often related to hypoxia secondary to respiratory etiologies. In rare situations it may exist in spite of adequate ventilation and oxygenation. Given the presence of a high degree heart blocks, or symptomatic bradycardia refractory to aggressive BLS and ALS treatments, transcutaneous cardiac pacing should be initiated without delay.

  • High degree heart blocks, often congenital
  • Symptomatic bradycardia refractory to ventilation, oxygenation, chest compressions, and pharmacological treatments
The only contraindication of TCP is an inability to place the pads on the patient without overlap or sufficient distance between them.

Side Effects
The side effects of TCP are most frequently muscle activation and associated pain. These are dose dependent effects which are a combination of the current delivered, size of the pads, location of the pads, and width (time) of the delivered pulse [1].

To minimize these side effects use the largest available pads, placing them in an Apical-Posterior fashion. While larger pads require higher current outputs, there is a decrease in the current delivered per surface area reducing the side effects associated with TCP.

Often, management of these side effects is achieved through concurrent pharmacological treatment with analgesics and/or sedatives.

Pediatric transcutaneous cardiac pacing (TCP) is defined by two dosing parameters: output current and rate. This guideline assumes the pacemaker is in fixed mode.

Output Current
As with adult patients, the output current for pediatric transcutaneous cardiac pacing should begin at 20 mA (or the lowest setting available) and increase in 5-10 mA increments until electromechanical capture is obtained. Additionally, the current may be increased an additional 5-10 mA above the determined threshold to ensure continued capture. If the device maximum output current is reached and no electromechanical capture exists, discontinue TCP and troubleshoot. Attempt an alternative pad placement (anterio-apical or anterior-posterior) and ensure the negative pad is on the anterior aspect of the chest. If capture is still not obtained, resume CPR and obtain expert consultation.

Output Rate
In contrast to adult patients, the output rate for pediatric transcutaneous cardiac pacing is age based. The final output rate should be titrated to an adequate systolic blood pressure to resolve perfusion problems, e.g. an improvement in mental status. Care should be taken to avoid tachycardic rates or hypertension. Consult a length-based resuscitation tape (e.g. Broselow™ tape) for appropriate starting output rates and systolic blood pressure. An example table is given below, adapted from the North Carolina 2009 EMS Standards [2]:

Rate (bpm)
Systolic BP (mmHg)
0-3 mo
85 (+/-25)
3-6 mo
90 (+/-30)
7-10 mo
96 (+/-25)
11-18 mo
100 (+/-30)
19-35 mo
100 (+/-20)
3-4 yr
100 (+/-20)
5-6 yr
100 (+/-15)
7-9 yr
105 (+/-15)
10-12 yr
115 (+/-20)
>12 yr
120 (+/-20)


Anonymous said...

According to the AHA PALS, you should start pediatric pacing at the highest number then dial down until you get capture.

Christopher said...


There is no such guidance in the 2010 PALS material. The only statements given are:

– Emergency transcutaneous pacing may be lifesaving if the bradycardia is due to complete heart block or sinus node dysfunction unresponsive to ventilation, oxygenation, chest compressions, and medications, especially if it is associated with congenital or acquired heart disease (Class IIb, LOE C).[293] Pacing is not useful for asystole293,294 or bradycardia due to postarrest hypoxic/ischemic myocardial insult or respiratory failure.

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