Nursing care
Transcutaneous pacing: pad placement, confirming capture, sedation and skin burns
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated October 2026
Short answer
Transcutaneous pacing sends current through pads on the chest to treat unstable bradycardia until a more definitive option is available. After increasing output until each spike produces a wide QRS, the nurse confirms mechanical capture with a pulse that matches the paced rate, gives ordered analgesia and sedation, and inspects the skin under the pads.
Purpose and preparation
Transcutaneous pacing is a rapid, noninvasive way to support a patient with haemodynamically unstable bradycardia or high-grade heart block that does not respond to medication. It is usually a bridge to transvenous pacing or a permanent device, not a long-term solution. The nurse prepares the monitor-defibrillator, connects ECG leads and explains the procedure if the patient is conscious.
Clip excess chest hair, dry the skin and remove any medicated patches from pad sites. Anterior-posterior placement is generally preferred: one pad over the left precordium and one on the back between the spine and left scapula. Anterior-lateral placement is an alternative. Avoid placing pads directly over an implanted device and over breast tissue.
Electrical capture: what the monitor shows
Select pacing mode, usually demand, set the rate ordered, and increase the output in milliamps gradually until every pacing spike is followed by a wide QRS complex with a broad T wave. This is electrical capture. Many protocols then set the output slightly above the capture threshold to maintain consistent capture.
Large pacing artefacts can mimic QRS complexes on the screen, so electrical capture on the monitor is not proof that the heart is pumping. Watch the trace after each spike carefully and look at the patient. Loss of capture can follow movement, pad lifting, sweat or a change in threshold, so recheck capture regularly and after any repositioning.
Mechanical capture: confirm with a pulse
Mechanical capture means each paced complex produces a heartbeat with a pulse. Confirm it by palpating a pulse that matches the paced rate, commonly the femoral pulse, or by an arterial waveform if one is present. Rising blood pressure, improved mentation and better skin colour support effective pacing. A pulse rate well below the paced rate suggests incomplete capture.
Skeletal muscle twitching in the chest and arm is expected and does not indicate cardiac capture. Muscle contraction near the neck can feel like a carotid pulse, so a site away from the pacing current is more reliable. If electrical capture is present without a pulse, treat the patient as pulseless and follow advanced life support algorithms.
Pain, sedation and skin injury
Pacing current causes painful muscle contraction, and discomfort often limits tolerance, especially at higher outputs. In a conscious patient, give prescribed analgesia and sedation as soon as possible without delaying pacing in an unstable patient. Once sedated, monitor airway, breathing, oxygen saturation and level of consciousness closely, as with any procedural sedation.
Burns under the pads have been reported, particularly with prolonged pacing. Inspect the skin regularly, replace pads according to manufacturer guidance, and report redness or blistering. Other complications include failure to capture from poor pad contact, hiccups and anxiety. Prepare for transvenous pacing as the provider directs.
Work a hypothetical capture question
In an invented item, a client is paced at a set rate and the monitor shows a wide QRS after every spike, with strong chest muscle twitching. The femoral pulse is 40 per minute while the paced rate is higher. Options include documenting successful capture, palpating the carotid instead, increasing output per protocol and notifying the provider, or stopping pacing.
Increasing output and notifying the provider is the best answer, because the pulse shows incomplete mechanical capture despite a convincing monitor. Twitching is not capture, and the carotid is less reliable during pacing because muscle contraction can mimic a pulse. Document rate, output, capture findings, sedation given, skin assessment and the patient's response.
Sources and further reading
OpenAnesthesia: Transcutaneous pacing. Pad positions, ECG appearance of capture, pulse correlation, pain as the limiting factor, analgesia, skin burns and failure to capture from poor contact.
Journal of Critical Illness (PMC): Using transcutaneous cardiac pacing to best advantage. Wide QRS and broad T wave with capture, confirming haemodynamic response with a pulse, sedation and analgesia, burns and anterior-posterior pad placement.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our cardiovascular practice questions are the closest set to what this page covers.
Common questions
What is the difference between electrical and mechanical capture?
Electrical capture is seen on the monitor as a wide QRS after each spike. Mechanical capture means the heart actually contracts, confirmed by a pulse matching the paced rate.
Why is the femoral pulse preferred to check pacing?
Pacing makes chest and neck muscles contract, which can feel like a carotid pulse. A femoral pulse, away from the pacing current, gives a more reliable check.
Does a conscious patient need sedation for transcutaneous pacing?
Usually yes, because the current causes painful muscle contraction. Give prescribed analgesia and sedation as soon as possible, but do not delay pacing in an unstable patient.
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