Emergency Medicine is Hard

Indications:

• Symptomatic or unstable bradycardia / AV Block
• Severe sick sinus syndrome with prolonged asystole (>3 seconds) and syncope
• Ventricular standstill due to complete heart block or Mobitz type II AV block
• Torsades de pointes (Overdrive pacing)
• Recurrent monomorphic ventricular tachycardia (Over drive pacing); risk of inducing Vfib
• Unstably SVT – only after pharmacologic intervention and cardioversion has failed

Preferred sites:

• Right internal jugular vein
• Left subclavian vein

Procedure:

1. Place cordis
2. Have an assistant plug the non-sterile side of the connecting cable into the generator
3. Confirm balloon inflates using the 1cc syringe; leave it deflated
4. Feed the wire through the smaller side of the sterile sleeve
5. Feed the wire at least 20 cm (two black lines) into the cordis; this places the balloon just outside the cordis sheath
6. Place the black adapter pins into the pacing wire and have an assistant plug them into the connecting wire (Negative to negative; positive to positive)
7. Have assistant change rate to 80 bpm and set output to 20 mA
8. Feed the wire 30 cm in (three black lines), and inflate and lock the inflated balloon
9. Using a subxiphoid view of the right ventricle or watch the cardiac monitor for a STEMI pattern in lead I
10. Once you have capture, turn down the current until you just lose capture, then go one above that
11. Deflate the balloon and lock
12. Pull the sleeve down to the cordis and open up the sterile sleeve

STEMI Pattern in Lead I

References

https://www.emrap.org/episode/transvenous/transvenous