The Journal of Emergency Medicine, Vol. 17, No. 6, pp.

1007–1009, 1999
Copyright © 1999 Elsevier Science Inc.
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Selected Topics:
Cardiology Commentary

USING ULTRASOUND TO DETERMINE EXTERNAL PACER CAPTURE

Douglas Ettin, MD and Thomas Cook, MD

Palmetto Richland Memorial Hospital, University of South Carolina School of Medicine, Columbia, South Carolina
Reprint Address: Thomas Cook, MD, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, 3 Medical Park,
Suite 350, Columbia, SC 29203

e Abstract—Transcutaneous cardiac pacing is a tempo-
rary treatment of hemodynamically unstable bradycardias.
However, the rhythmic skeletal muscle contractions that
occur during external pacing can make it difficult to assess
the hemodynamic status of the patient. We report a case of
using bedside ultrasound to assess the effectiveness of trans-
cutaneous pacer capture. © 1999 Elsevier Science Inc.
e Keywords—transthoracic pacing; transvenous pacing;
ultrasonography; echocardiography; bradycardia
INTRODUCTION
Transcutaneous cardiac pacing is a temporary measure for
the treatment of hemodynamically significant bradycar-
dias that do not respond to medical therapy (1). A pitfall
of overdrive pacing is that the threshold for capture may
change, leading to failure of the transcutaneous pacer (2).
We report the use of bedside ultrasound to verify the
effectiveness of transcutaneous overdrive pacing.
CASE REPORT
A 42-year-old female presented from a local correctional
facility with the complaint of sharp substernal chest pain
for approximately 10 h. At the prison infirmary, she had
received hydroxyzine for her symptoms without relief.
The patient eventually developed hypotension, bradycar-
dia, and a decreased level of consciousness, prompting
transfer to our facility. During transfer, she had a heart
rate of 30 beats/min and no measurable blood pressure.
The patient was treated en route with atropine and an i.v.
fluid bolus without improvement of her symptoms. Her
past medical history was significant for hypertension and
supraventricular tachycardia. A coronary catheterization
2 years earlier was normal. Her medications included meto-
prolol and verapamil. She had no known drug allergies.
Upon arrival, the patient’s initial vital signs were a
blood pressure of 58/30 mmHg, a pulse rate of 37 beats/
min, and a respiratory rate of 28 breaths/min. The phys-
ical examination revealed equal, slowly reactive pupils,
approximately 3 mm in size. The oral mucosa was moist
and pink, and the neck was supple without jugular venous
distension. The pulmonary examination was notable for
diminished breath sounds at the bases. The cardiac exami-
nation revealed an irregular bradycardia. The abdomen was
soft and nondistended. Distal pulses were absent in all
four extremities. There was no edema. The patient was
somnolent but arousable to verbal and tactile stimulation.
An electrocardiogram (EKG) revealed a wide-com-
plex bradycardia with atrioventricular dissociation.
There was no evidence of cardiac ischemia or injury. The
patient was initially treated with an i.v. bolus of normal
saline and i.v. calcium chloride without effect. Transcu-
taneous pacing was started at 100 beats/min with a cur-

RECEIVED: 4 January 1999; FINAL SUBMISSION RECEIVED: 13 April 1999;

ACCEPTED: 28 April 1999
1007
1008
rent output of 80 mA. Good capture was noted on the
EKG monitor, and the patient developed a strong radial
pulse with an improved mental status. The patient’s
blood pressure increased to 100 mmHg systolic. Shortly
after the initiation of cardiac pacing, the patient began to
complain of pain from the pacer shocks. The current
output was adjusted to the lowest setting that would still
maintain ventricular capture by EKG monitoring (70
mA). Despite this adjustment, the patient continued to
complain of pain and was sedated with lorazepam.
Shortly after cardiac pacing was initiated, the pa-
tient’s systolic blood pressure dropped to 50 mmHg. The
EKG monitor continued to demonstrate adequate ven-
tricular capture by the pacer. The patient appeared to
have palpable pulses; however, the rhythmic contractions
of the patient’s body from the pacer shocks made this
assessment difficult. With the etiology of the patient’s
hypotension unclear, the decision was made to use trans-
thoracic ultrasonography to assess the adequacy of her
ventricular contractions.
Using a Shimadzu SDU-400 ultrasound machine with
a 3.5 MHz transducer, subxiphoid and parasternal views
of the heart were obtained. Initially, the ultrasound dem-
onstrated ventricular contractions at a rate of 30 – 40
beats per minute. These heart contractions did not cor-
respond with the surrounding thoracic muscle contrac-
tions generated by the pacer. The current output was
gradually increased to 110 mA, and the heart began to
contract in unison with the pacer shocks. The patient’s
blood pressure subsequently increased to 90 mmHg.
Because of the patient’s discomfort from the pacing,
additional sedation was required. Subsequently, the pa-
tient required intubation for respiratory depression. Cen-
tral venous access was obtained to prepare for placement
of a transvenous pacer, and the patient was admitted.
During admission, serial cardiac enzymes were neg-
ative for myocardial infarction. Electrophysiologic stud-
ies revealed severe sinus node disease without other
significant conduction abnormalities, and a DDDR pace-
maker was placed. The remainder of the patient’s admis-
sion was uneventful. An EKG before discharge showed
good capture with a normal rhythm.
DISCUSSION
Transthoracic pacing is a proven modality for the tem-
porary stabilization of patients suffering from inadequate
cardiac output secondary to bradycardia from a variety of
causes (1). Currently, the ability of the physician to
assess the adequacy of ventricular contractions during
transthoracic pacing is limited to indirect parameters
such as EKG monitoring and physical examination for
corresponding arterial pulsations.
D. Ettin and T. Cook
With electrocardiography, if the monitor being used is
separate from the pacer unit, the electrical current output
may not be filtered, resulting in pacer spikes on the
monitor that drown out the QRS complex. This process
may mask an underlying dysrhythmia (1). In addition,
similar to the pulseless electrical activity that is noted
during cardiac arrest, the electrical activity recorded on
the EKG monitor with overdrive pacing may not give an
accurate indication of cardiac contractility. In this case,
the EKG monitor used was part of the pacing unit, and
therefore, the waveform observed was not related to the
effect of unfiltered pacer current output. The EKG wave-
form noted on the monitor appeared to indicate adequate
capture, yet the ultrasound did not demonstrate corre-
sponding contractions.
Because transthoracic pacing causes contractions of
the skeletal muscles over the thorax and extremities,
medical personnel may misinterpret these contractions
for arterial pulsations. This could lead one to incorrectly
assume that the heart is generating sufficient cardiac
output, thereby leading to an ineffective search for other
etiologies of a patient’s deterioration. In this case, exam-
ination for the presence of arterial pulses seemed to
indicate that transthoracic pacing was generating an ad-
equate cardiac output; however, the patient’s persistent
hypotension contradicted this finding, leading to the de-
cision to directly visualize the heart by ultrasound.
Over the past decade, ultrasonography has played an
increasing role in the care of emergency department
patients (3– 6). The ability to use this technology gives
emergency physicians immediate feedback and facili-
tates the rapid diagnosis of a variety of life-threatening
problems. By using ultrasound, emergency physicians
can more efficiently diagnose and manage aortic aneu-
rysm rupture, ectopic pregnancy, cholecystitis, hemo-
peritoneum, and pericardial effusion (3–5,7).
This case presents another use for ultrasound to facil-
itate the care of seriously ill patients in the emergency
department. Physicians have studied the use of echocar-
diography in the evaluation of pulseless electrical activ-
ity (PEA). In one such study, 19 out of 22 patients (86%)
who had electrocardiographic findings and no palpable
pulses were found to have myocardial wall motion (8).
Others have confirmed this finding (9). These findings
add credence to the idea that ineffective cardiac output in
a patient without palpable pulses will appear clinically as
PEA. Ultrasound can be used to determine the presence
of adequate cardiac contractions and rate.
CONCLUSION
This case illustrates the use of emergency ultrasound to
determine the effectiveness of transcutaneous overdrive
pacing. Future research in this area is warranted.
Ultrasound To Determine External Pacer Capture
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