EMERGENCY DEPARTMENT · WALL POSTER

Transvenous Pacing (TVP)

DECIDESymptomatic bradyarrhythmia unresponsive to drugs and pacing pads — Symptomatic Bradycardia first. · Access order: right IJ ≫ left subclavian ≫ left IJ ≫ right subclavian.

STEPS · ◆ KEY STEP — LOGGED WITH ITS TIME

FLOAT, CAPTURE & SETTINGS — STEP BY STEP

Test the balloon in saline (1.5 mL, no leak). Sleeve on before insertion. Distal = negative.
Set before floating: rate 80/min, output maximal at 20 mA, asynchronous/non-sensing.
Advance to 15–20 cm (just beyond the sheath tip), then inflate the balloon gently and lock it.
Float watching for both captures — paced QRS and a real pulse. RV is ~30–40 cm from a right IJ.
On capture: stop. Deflate the balloon passively — unlock and let it empty. ◆ CAPTURE — PACING
Threshold: turn output down until capture is lost, then set at 2× that. Ask for a cough.
Sensitivity: switch to demand (VVI), find the sensing threshold, set at about half.
Secure: lock the sleeve, suture the sheath, loop and tape the wire, hang the generator.
Confirm: CXR — tip at the RV apex, crossing the midline. 12-lead — paced LBBB, superior axis.

EQUIPMENT

Introducer sheath kit (Cordis-type) 6–7 Fr, with its integral sterile sleeve.
Balloon-tipped bipolar pacing catheter, 5 Fr, marked every 10 cm. Syringe capped at 1.5 mL air.
External generator with a fresh battery, plus its connecting cable.
Ultrasound at the bedside. Pads on and push-dose epinephrine drawn up as backup.
Standard central-access sterile bundle (as per the CVC card) + suture.

IN THE KIT — 6 ITEMS · ROOM 7 (RESUS BAY) CABINET · TRANSVENOUS PACING

Introducer sheath 6–7 Fr with sterile sleeve — Cordis-type, its own sheath ×1
Balloon-tipped bipolar pacing catheter 5 Fr — depth-marked every 10 cm ×1
Balloon syringe capped at 1.5 mL ×1
Connecting cable ×1
Suture 2-0 + needle driver ×1
Sterile probe cover + gel — mechanical-capture confirmation ×1

ALSO NEEDED — NOT IN THE KIT

External generator with a fresh battery, stored beside the bag. Standard central-access sterile bundle from the CVC shelf. Transcutaneous pads on and push-dose epinephrine drawn up before you start.
DRAFT — not yet assembled or signed off. Find the generator and check its battery on the monthly check.

FIGURE

Set rate and output before floating; confirm mechanical capture, then turn down to find threshold and set the final output.

OUTPUT 20 MA → THRESHOLD <1 MA → SET 2×

RATE 80 · ASYNC TO START

BALLOON 1.5 ML AIR · INFLATE ONLY BEYOND 15–20 CM

RIJ → RV ≈ 30–40 CM · NEVER ADVANCE PAST ~50 CM

PITFALLS & PEARLS

Advancing with the balloon down (perforation risk) or withdrawing with it up (valve injury).

Coiling in the RA/IVC — depth keeps rising without capture: deflate, pull back to 20 cm, re-float.

Calling capture from pacing spikes or artefact without a mechanical pulse check.

Output left at bare threshold → capture lost with a cough or movement — that is why it is set at 2× threshold.