Atropine is often considered a first-line intervention for unstable bradycardia. Unfortunately, atropine often fails when the bradycardia is not vagally-induced and is not indicated for high-level atrioventricular (AV) blocks (eg, Mobitz II and third-degree AV block).
Transvenous pacing is typically the most effective therapy for unstable bradycardia but it is invasive, takes some time to perform, and is a procedure for which many acute care physicians lack comfort and significant experience. Transcutaneous pacing (TCP), on the other hand, is fast, easy to perform, and tends to be well-tolerated by most patients when they receive appropriate doses of analgesia.
Unfortunately, TCP often fails to produce electrical or, more importantly, mechanical capture. Oftentimes when capture initially fails, the electrical current is increased in hopes of gaining capture but much to the discomfort of the patient. Increased body mass index can contribute to failure to capture, but what about TCP pad position? Despite recommendations for TCP in the United States and European resuscitation guidelines for many years, until now, no studies have evaluated optimal pad position for TCP. As a result, the default position for most clinicians using TCP has been the anterior-lateral (AL) position on the chest wall.
