Josh Kimbrell

Thanks for sharing! Totally agree.

Phenomenal write up for anyone working in EMS/Code Team/RRT quality and safety. I will be referencing this. TCP is always thrown out as "what they should have done"-- but lit is showing this is a low success maneuver. I'll still do it-- but good to escalate chronotropes and prep for TVP.

Here are some additional resources :
www.tandfonline.com/doi/full/10....
www.resuscitationjournal.com/article/S030...
www.stryker.com/content/dam/...
www.foamfrat.com/post/podcast...

This was a labor of love, thanks to the many coauthors on this project who toiled on this project for many months.

Please read our manuscript published in @resuscitation.bsky.social with this free link: kwnsfk27.r.eu-west-1.awstrack.me/L0/https:%2F...

Here are my ideas for improved success:

Educate on false electrical capture
Ensure patients are ideal TCP candidates
Start with chronotropes first
Start with A/P pad positioning
Deliver higher currents
Print ECGs during TCP
Confirm with all available tools: SPO2, ETCO2, POCUS

Anteroposterior Pacer Pad Position Is More Likely to Capture Than Anterolateral for Transcutaneous Cardiac Pacing | Circulation

Previous studies also suggest we might need high currents to have a chance.

In these hospital studies on non-emergently ill patients, high currents were required and sometimes capture was not possible at even max currents.

tinyurl.com/TCPAPAL
tinyurl.com/TCPALAP

Now, what do we do to fix this? Do we give up on TCP entirely?

I don't think these data support that. But I do think we need to re-evaluate both when we perform TCP and retrain how we do it.

(If anyone can muscle through a TCP vs. Meds RCT though, I'd support it!)

Identifying causal contributors with this observational dataset is fraught with issues, but it seems plausible that lower currents, large patients, and patients with higher heart rates could contribute to this problem. We adjusted for variables as suggested by our DAG.

We used a regression model to attempt to identify what factors were associated with sustained electrical capture. We found three things:

Higher Max Current (per 10mA): aOR 1.25 (95% CI: 1.08-1.45)
Lower Body Weight: 0.95 (0.93-0.98)
Lower pre-TCP Heart Rate: 0.96 (0.93-0.99)

The literature makes clear that palpating a pulse on patients that are unresponsive and pulseless is difficult.

Now, imagine that your patient has violent musculoskeletal contractions with every pace fire. And then, they have an underlying rhythm.

See why it might be hard?

I know what you're thinking. Why don't they just feel for a pulse?!

Of 299 patients, 170 (56.9%) had documentation of confirmed pulse palpation. Of these, 124 (72.9%) had no electrical capture.

How, if they felt a pulse?

Safe to say, sustained electrical capture seems rare during TCP in the prehospital setting.

I suspect this is due to a few factors: complexity in ECG interpretation, rarity of the event, inadequate training with low currents achieving capture in simulation, and more.

Abstract Sun1205: Transcutaneous Pacing in the Prehospital Setting – Challenges, Limitations and Opportunities for Improvement | Circulation Introduction: Transcutaneous pacing (TCP) is an emergent procedure used in the prehospital setting to treat hemodynamically unstable bradycardia. Prior studies have questioned the efficacy of prehospi...

Could this be because these clinicians suck extraordinarily at TCP? Maybe... But what if we looked at a different high-performing system?

Well, Seattle did. In their study (n=59), only 13.8% of attempted TCP time had complete electrical capture.
www.ahajournals.org/doi/10.1161/...

We searched through hours of ECG waveforms and identified that only 29/299 (9.7%) had ECG characteristics consistent with ventricular depolarization (sustained electrical capture) for > 90% of the time TCP was firing.

224 (74.9%) never had even intermittent electrical capture.

Interpretation is more challenging than it sounds. Take a look at this image, which shows an electrical artifact with a wide "swooping" shape.

Interpretation is difficult, as this phantom complex (circled) gets larger with higher currents. It looks pretty wide and bizarre...

We identified 299 patients from 4 prehospital paramedic services in the US with at least 60s of TCP attempted.

We reviewed the ECG file to determine whether ECG characteristics were consistent with ventricular depolarization, electrical capture, for the duration (>90%) of TCP.

TCP is taught like this:

1) If patient is unstable and bradycardic, try atropine
2) If that doesn't work, apply pads
3) Set rate at 60-80/min
4) Increase current until wide and bizarre complexes are visualized with each pacer
5) Confirm with pulse palpation

Easy, right?

Transcutaneous pacing (TCP) is an intervention for unstable bradycardia. Electrical stimulus is provided ~1/s to increase heart rate. With transvenous pacers and chronotropic meds, TCP is mostly limited to the prehospital setting and low-resource centers.

We suck at TCP. #emimcc #medsky #cardiosky

Methods Four emergency medical services agencies contributed patients who received TCP from 2017-2024. Data were abstracted from electronic health records and cardiac monitor files. Sustained electrical capture was defined as a wide QRS complex with a T-wave after each pacer impulse for at least 90% of a 60 second period, followed by electrical capture for 90% of the remainder of the TCP attempt. Multivariable logistic regression modeling was used to estimate the association between variables of interest and sustained electrical capture. Results Of 299 patients, 29 (9.7%) had sustained electrical capture. Our cohort was a median 73 [62, 82] years of age, 48.5% (n=145) female, and 33.8% (n=101) had post-ROSC TCP. The median body weight was 78.3 [68-95.3] kilograms, pre-TCP heart rate was 38 [30, 45] beats per minute (bpm) and maximum TCP current was 90 [70-110] mA. Lower weight (aOR: 0.95 [0.93, 0.98] per kg; n=208), lower pre-TCP heart rate (aOR: 0.96 [0.93, 0.99] per bpm; n=297), and higher delivered current (aOR: 1.25 [1.08, 1.45] per 10 mA; n=208) were associated with higher odds of sustained electrical capture

If you're going to use transcutaneous pacing, dial up the milliamps!
That dial goes up above 100 for a reason.
Study headed up by Tanner Smida and @joshkimbre.bsky.social
(COI: I'm co-author 8/13)
www.resuscitationjournal.com/article/S030...

When intubating with VL, the cords should be as far away as possible, while still visible. Large cords=close camera=blocked tube delivery. #EMsky #EMS @mdaware.org @joshkimbre.bsky.social

Wedding Ceremony recessional dip with a kiss.

Groom licks cake knife and bride is aghast.

Bride and groom in parasols, beer in hand, for the second line parade in the New Orleans wedding.

Mid-vows shot of the wedding ceremony in Hotel Peter & Paul, an historic building that was previously a Catholic Church with vaulted ceilings, hanging lanterns, stained glass windows, and a semicircular altar.

Been away for awhile having the time of my life. I usually stick to medicine here but figured y'all could take a peek at my personal life today.

You can go to a strip club or a casino tho! 😅

you couldn't waterboard this out of me

New RCT: Avoiding A-line in shock didn't affect mortality (trend towards *reduction*) & decreased line complications

They avoided A-lines despite patients requiring pretty substantial doses of vasopressors

Very #zentensivist

Don't need to rush to an A-line

www.nejm.org/doi/full/10.... #EMIMCC

MASSIVE RCT from Kenya showing that steroids reduce mortality in CAP

Mortality benefit easier to demonstrate w/ less resources available to salvage pts

Should allay the hype that the negative REMAP-CAP steroid RCT received (despite being woefully underpowered)

www.nejm.org/doi/pdf/10.1... #EMIMCC

Remembering the most likely mediator of reduced mortality in the original EGDT therapy was the presence of the CI in the intervention arm, the regular attendance of an interested and informed clinician (and skilled ICU nurse) likely has a bigger impact than any single drug or intervention.

More recent studies have underscored persistent challenges for clinicians in achieving and maintaining both electrical and mechanical capture during pacing

False Electrical Capture in Prehospital Transcutaneous Pacing by Paramedics: A Case Series. Prehosp Emerg Care. 2024;28:928–936. doi: 10.1080/10903127.2024.2321287

New ACLS guidelines highlight the perils of failed capture during pacing.
@joshkimbre.bsky.social
Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines share.google/43YFnH7VcuFJ...

Thanks for highlighting! It was pretty cool to see. Hopefully we can push harder with future work and really provide enough data to inform practice.

Thanks Mitch! It is really cool--hoping this and future work in TCP can further inform guidelines and practice.