Children with a severe bradycardia or asystole may respond to pacing. Because transvenous pacing requires central venous access with large tubing and proficient skill in placing the pacing electrodes, most emergency practitioners and prehospital providers should only attempt transcutaneous pacing. Adult patches should be used in children who weigh over 15 kg.11 The negative electrode patch should be placed on the anterior chest at V 3, and the positive electrode patch is placed on the posterior chest between the shoulder blades at the T4 vertebral level.12 Ventricular capture is determined by the palpation of a pulse or the appearance of an arterial waveform if an arterial pressure catheter is present. Begin with the maximal energy output.12 If ventricular capture occurs, then decrease the energy setting progressively until the lowest setting is found that allows ventricular capture. The pacing rate should be set at a rate slightly higher than the normal rate for age. Transcutaneous pacing has not been associated with greatly improved survival rates, but it can be life-saving if applied quickly in a child with sudden asystole or bradycardia.
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