safety margin for transcutaneous pacing

Thomas SP, Thakkar J, Kovoor P, Thiagalingam A, Ross DL. Cardiac pacing. Sinus bradycardia may have many causes. Philadelphia: Elsevier; 2019. p. 45660. [PMID:8558949], 3. Acute myocardial infarction complicated by ventricular standstill terminated by thrombolysis and transcutaneous pacing. Trigano AJ, Azoulay A, Rochdi M, Campillo A. Electromagnetic interference of external pacemakers by walkie-talkies and digital cellular phones: experimental study. The patients blood pressure improves slightly to 84/47 (confirmed by auscultation). [QxMD MEDLINE Link]. As the mA output is increased, complete capture is achieved. &H0R mlt DZB Dz@}g{6=y4;sWy@,K2@ 2023 ACLS Medical Training, All Rights Reserved. This rate can be adjusted up or down (based on patient clinical response) once pacing is established. Transcutaneous cardiac pacing may be associated with discomfort such as a burning sensation of the skin, skeletal muscle contractions, or both. Transcutaneous Cardiac Pacing. Rosenthal E, Thomas N, Quinn E, Chamberlain D, Vincent R. Transcutaneous pacing for cardiac emergencies. The posterior electrode, which should be of positive polarity, should be placed inferior to the scapula or between the right or left scapula and the spine; it should not be placed over the scapula or the spine. Safety and efficacy of noninvasive cardiac pacing. You should know the major AV blocks because important treatment decisions are based on the type of block present. 52(1):111-6. -q-1gj+T!LcLm3cQrZH'm You need to have some way to tell that the heart is being paced and generating a blood pressure; have a pulse oximeter or arterial line waveform for confirmation of the monitors electrical activity. Also, complete or third-degree AV block is the degree of block most likely to cause cardiovascular collapse and require immediate pacing. Ottawa: University of Ottawa. Alternatively, the positive electrode can be placed anteriorly on the right upper part of the chest (see the image below). Ramin Assadi, MD Assistant Professor of Medicine, Division of Interventional Cardiology, University of California, Los Angeles, David Geffen School of Medicine Three common causes of bradycardia in the emergency department include drugs (specifically overdoses) hyperkalemia, and myocardial ischemia: While most textbooks may quote overdrive pacing for refractory tachyarrhythmias, practically speaking, most of these will get simply get cardioverted, TCP is only a bridge until a transvenous pacemaker can be placed, There are a few instances where TCP may be preferable over TVP, Patients who may respond to respond to therapy (eg. 2002;25(2):2604. . Springer, Cham. Explain the purpose of TCP to your patient. Current is applied until electrical capture (characterized by a wide QRS complex since the SA node-AV node conducting pathway is bypassed, with tall, broad T-waves on the EKG) occurs. If your employer verifies that they will absolutely not accept the provider card, you will be issued a prompt and courteous refund of your entire course fee. An overview of physiology of transcutaneous and transvenous pacemak ers has been added. 2013 Aug. 15(8):1205-9. Transcutaneous Cardiac Pacing Periprocedural Care Consider this excerpt from the Journal of Emergency Medicine where Douglas Ettin, M.D. muscle artifact). 4. Most patients cannot tolerate currents of 50 milliamps and higher without sedation. 2020 Dec. 31(12):3277-85. Am J Emerg Med. University of Ottawa Heart Institute: Temporary Cardiac Pacing. How to provide transcutaneous pacing. During TCP, pads are placed on the patients chest either in anterolateral position or anterior-posterior (AP) position. In this chapter we discuss the implications of a slow heart rate and the treatment options available including how to place these temporary pacing devices and trouble-shooting to achieve the best clinical outcome. [QxMD MEDLINE Link]. By continuously monitoring his cardiac rate and rhythm and delivering pacing impulses through his skin and chest wall muscles as needed, TCP causes electrical depolarization and subsequent cardiac contraction to maintain cardiac output. 2007 May. Temporary cardiac pacing (TCP) is a type of exogenous cardiac pacing in which an external energy source delivers electrical impulses to stimulate the heart to contract faster than its native rate. A defibrillator with pacing capability. 2018:bcr-2018-226769. The patient appeared to have palpable pulses; however, the rhythm contractions of the patients body from the pacer shocks made this assessment difficult. Stop advancing the pacing wire when 4 to 5 cm remains outside the cannula. Capture achieved at 140 mA and confirmed with sudden rise in ETCO2 (ems12lead.com). endstream endobj 128 0 obj <>stream Share cases and questions with Physicians on Medscape consult. When capture occurred, each pacing artifact was followed by a QRS complex (albeit bizarrely shaped) and pulse. Technique: Ideal pacer pad placement sandwiches the heart between the pacing pads and mimics the hearts normal electrical axis. Simply email us through the contact us link displayed on every page of this website any time within 60 days of purchase. The problem of false capture (also known as echo distortion) is under-recognized and under-reported in the medical literature. may email you for journal alerts and information, but is committed External transcutaneous pacing has been used successfully for overdrive pacing of tachyarrhythmias; however, it is not considered beneficial in the treatment of asystole. Jaworska K, Prochaczek F, Galecka J. Permanent-temporary pacemakers in the management of patients with conduction abnormalities after transcatheter aortic valve replacement. These heart contractions did not correspond with the surrounding thoracic muscle contractions generated by the pacer. 84(3 Pt 1):395-400. This rate can be adjusted up or down (based on patient clinical response) once pacing is established. Try to avoid abrading the skin when shaving excess hair, to remove a foreign body, to clean the skin, and to review and address the above-mentioned factors that may increase the pacing threshold. Christian Schroder How to determine paccing threshold? Ali A Sovari, MD, FACP, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Physician Scientists Association, American Physiological Society, Biophysical Society, Heart Rhythm Society, Society for Cardiovascular Magnetic ResonanceDisclosure: Nothing to disclose. Pacing thresholds may change without warning and capture can readily be lost. [QxMD MEDLINE Link]. With the etiology of the patients hypotension unclear, the decision was made to use transthoracic ultrasonography to assess the adequacy of her ventricular contractions., Initially, the ultrasound demonstrated ventricular contractions at a rate of 30-40 beats per minute. Craig, Karen RN, BS. These modifications allow administration of higher currents with less patient discomfort. Hemodynamic responses to noninvasive external cardiac pacing. Indications: Hemodynamically significant (hypotension, chest pain, pulmonary edema, altered mental status) bradydysrhythmias unresponsive to atropine, asystolic cardiac arrest (more likely to be successful when initiated early after a witnessed arrestunwitnessed arrest seldom responds to transcutaneous pacing), failed intrinsic pacemaker. Symptomatic clinically significant bradycardias, Don't just treat a number. Houmsse M, Karki R, Gabriels J, et al. Transcutaneous Pacing Downeast Emergency Medicine Medication Summary The goal of pharmacotherapy is to provide sedation and pain medication to relieve the discomfort, such as burning sensation of the skin and/or skeletal muscle contractions that. Please confirm that you would like to log out of Medscape. describe the difficulty. 19(2):134-6. Your message has been successfully sent to your colleague. If capture is maintained but the patient remains symptomatic of inadequate tissue . Transcutaneous Pacing - an overview | ScienceDirect Topics You must decide if the patient has adequate or poor perfusion: If the patient has poor perfusion secondary to bradycardia the treatment sequence is as follows: Technique: Perform Transcutaneous Pacing are as follows: Most patients will improve with a rate of 60 to 70/min if the symptoms, Online Resources For Primary Care Physicians, 2018 ACLS Review The Tachycardia Algorithm Part 5 From The ACLS Manual, Reviewing Episode 13 Part 2: Killer Coma Cases The Intoxicated Patient From Emergency MedicineCases, Reviewing Episode 13 Part 1: Killer Coma Cases The Found Down Patient From Emergency Medicine Cases, The Best Way to Start a Podcast PCI 333 From Blubrrys Pod, Sturge Weber Syndrome Podcast From PedsCases With A Link To An Additional Resource, Neurofibromatosis Type 1 (NF1) From PedsCases With Links To Additional Resources, Approach To Childhood Glaucoma Podcast From PedsCases, Reviewing Episode 33: Oncologic Emergencies From Emergency Medicine Cases, Linking To The Referring Physician Imaging Ordering Guide: What to Order When From Radia, Oncologic Emergencies (Part2) From EMC Rapid Review Videos, Oncologic Emergencies (Part 1) From EMC Rapid Review Videos, Postmenopausal Bleeding From StatPearls, Anaphylaxis and Anaphylactic Shock From Emergency Medicine Cases, #382 Abnormal Uterine Bleeding From The Curbsiders With Links To Additional Resources, False negative point-of-care urine pregnancy tests in an urban academic emergency department: a retrospective cohort study-Links And-Excerpts, Links To A Minicourse On Subarachnoid Hemorrhage By Dr. Chris Nickson From Life In The Fast Lane, Coma-like Syndromes By Dr. Chris Nickson From Life In The Fast Lane, Best Case Ever 22: Nonconvulsive Status Epilepticus (NCSE) From Emergency Medicine Cases, Non-Convulsive Status Epilepticus From EM Quick Hits, Link And Excerpts From Long QT From StatPearls With An Additional Resource And A Caveat, Genetic Diseases 3: Genetic testing technologies From Pedscases, Genetic Diseases 2: X-linked inheritance From PedsCases, Link To And Excerpts From Syncope From StatPearls, Genetic Diseases 1: Autosomal dominant inheritance From PedsCases With A Link To A Resource On Long QT Syndrome, Two Lists From The New York Times: 50 Best Netflix Films Now And 50 Best Netflix TV Series Now, Links To Stanford Medicine 25s 10 Video Introduction To Ultrasound Series (Point of Care, POCUS), Common Mistakes in Point of Care Cardiac Ultrasound (Echocardiography, POCUS) From Stanford Medicine 25, Point of Care Cardiac Ultrasound (Echocardiography, POCUS) From Stanford Medicine 25, Basic cardiac POCUS: image acquisition-A Teaching Video From UBC IM POCUS, Link To Complete List Of ACOG Guidelines With Links To Some Examples, Autonomic Failure & Orthostatic Hypotension From Dysautonomia International, Differentiate between signs and symptoms that are caused by the slow rate versus those that are unrelated, Correctly diagnose the presence and type of AV block, Use atropine as the drug intervention of first choice, Decide when to initiate transcutaneous pacing (TCP), Decide when to start epinephrine or dopamine to maintain heart rate and blood pressure. Circulation. Successful transcutaneous pacing in 2 severely hypothermic patients. Abraham G Kocheril, MD, FACC, FACP, FHRS Professor of Medicine, University of Illinois College of Medicine The size of the electrode pads usually ranges from 8-15 cm, and the pacing electrodes can be applied by medical personnel. A symptomatic bradycardia exists when 3 criteria are present: You must perform a focused history and physical examination to identify the signs and symptoms of a bradycardia. Temporary Cardiac Pacing | SpringerLink Expose the patients torso, turn on monitor and apply leads, Confirm bradyarrhythmia and signs and symptoms indicating TCP, Attach Defib pads on torso as recommended by manufacturer anterior/posterior, Explain. Murdock DK, Moran JF, Speranza D, Loeb HS, Scanlon PJ. Any part of the conduction axis may be affected including sinus node, AV node, or bundle branches. Implantation of leadless pacemakers via inferior vena cava filters is feasible and safe: Insights from a multicenter experience. Transcutaneous Pacing (TCP) With and Without Capture Zoll PM, Zoll RH, Falk RH, Clinton JE, Eitel DR, Antman EM. 1999 Nov-Dec. 17(6):1007-9. Usual practice is to have a pacing safety margin of at least 2 times (or 3 times if the patient has an unstable escape rhythm) - if the pacing threshold is 3, set at 7 (or 10). 2015 Nov. [cited 2019 July 22]. Assess his hemodynamic response to pacing by assessing his central pulses (see Cautions for using TCP) and taking blood pressure (BP) on both arms. 9% normal saline is run wide open with an additional IV line established in the left lower extremity. Webster J G, and Tompkins W J et al. [15]. Pulses are difficult to palpate due to excessive muscular response. Transvenous Pacing - an overview | ScienceDirect Topics METHOD OF INSERTION AND/OR USE place pads in AP position (black on anterior chest, red on posterior chest) connect ECG leads set pacemaker to demand turn pacing rate to > 30bpm above patients intrinsic rhythm set mA to 70 start pacing and increase mA until pacing rate captured on monitor We guarantee the ACLS Medical Training provider card will be accepted worldwide and offer a 100% money back guarantee. Patients requiring a permanent system should only undergo temporary pacing for syncope at rest, haemodynamic compromise, or bradycardia-induced ventricular tachyarrhythmias. Cardiac output is defined as the amount of blood the heart pumps out per minute and is the product of stroke volume and heart rate. Modern devices are capable of delivering up to 140-200 mA tolerably. Temporary cardiac pacing | Pacemakers and ICDs | Oxford Academic Note that pacing temporary wires at unnecessarily high outputs may lead to premature carbonisation of the leads and degradation of wire function. 148 0 obj <>/Filter/FlateDecode/ID[<080B985F646C544C9743A9819668209B>]/Index[124 45]/Info 123 0 R/Length 115/Prev 507343/Root 125 0 R/Size 169/Type/XRef/W[1 3 1]>>stream Learn how temporary noninvasive cardiac pacing can protect your patient until normal conduction is restored or he receives a transvenous pacemaker. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Pacing Clin Electrophysiol. Part of Springer Nature. Use an instrument (SpO2, Doppler, capnography, or echo) to help confirm mechanical capture whenever possible. Temporary Transvenous and Transcutaneous Pacemakers Transcutaneous pacing (TCP) with true electrical capture as evidenced by tall, broad T-waves. Undersensing: when a pacemaker fails to detect intrinsic activity, and therefore delivers a pace pulse. Transcutaneous cardiac pacing in a patient with third-degree heart block. 71(5):937-44. Sedation and analgesia can be considered when consulting a Base Hospital Physician to tailor the management plan to the patient. If still no ventricular capture is achieved further attempts to reposition the TPW should be made. Chest. Falk RH, Zoll PM, Zoll RH. The adult pads are placed and transcutaneous pacing is initiated. Pacing Clin Electrophysiol. The latter configuration does not affect the pacing threshold. B, No skeletal muscle contraction/movement occurred while pacing with the extracardiac lead at 2.7 V. This is supported by the unchanging accelerometer signals before and after pacing is delivered. Transcutaneous pacing - OpenAnesthesia Medscape Medical News. More examples of transcutaneous pacing (TCP) with capture. Transcutaneous pacing requires only pacing pads, EKG leads, . 2006 Aug. 70(2):193-200. Skin burns, pain, discomfort, and failure to capture are the main limitations of this method. However, paramedics are still concerned about the patient's hypotension. Advance the pacing wire through the cannula and into the ventricle. Clip excessive body hair if necessary (shaving could cause tiny nicks in the skin, causing pain and irritation). [21]. Snoring respirations are noted and a slow carotid pulse is present. Third-degree burns associated with transcutaneous pacing. When bradycardia is the cause of symptoms, the rate is generally less than 50/min. ACLS Medical Training does not provide medical advice, diagnosis, or treatment. Increasing mA beyond initial electrical capture threshold What is the safety margin for a transcutaneous pacemaker? Also assess your patient's pain and administer analgesia/sedation as ordered to ease the discomfort of chest wall muscle contractions. This will pause the TCP spikes for a few seconds so you can identify the underlying rhythm. EKG- Transcutaneous Pacing Flashcards | Quizlet Project the cash flows ten years into the future, and repeat steps one and two for all those years. SVT with Aberrancy or Ventricular Tachycardia? 22(4 Pt 1):588-93. It is important to educate the patient about the procedure and especially about potential discomfort related to skin tingling and burning and associated skeletal muscle contractions. Medscape Education. 60/min and milliamps to 0, Increase mA until electrical capture is obtained, Check to ensure the patient has mechanical capture ( Do not asses the carotid pulse for confirmation; electrical stimulation causes muscle jerking that may mimic the carotid pulse), Set the output 2 mA above the dose at which consistent mechanical capture is observed as a safety margin, reassess the patient to confirm if they are now hemodynamically stable ( increase rate as needed), reassess the patient to determine id sedation is now needed ( if not already administered), Advanced Airway - Endotracheal Intubation, Bio Chapter 20 pre lecture : Evolution of lif. Am J Med. Circulation. Please try after some time. The EKG monitor continued to demonstrate adequate ventricular capture by the pacer. How to Calculate Warren Buffett's Margin of Safety: Formula + Excel 2016 Nov. 34(11):2090-3. 1999 Apr. In: Brown DL, editor. [Guideline] Epstein AE, DiMarco JP, Ellenbogen KA, et al. The indications can be split into two broad categories: emergency (commonly with acute myocardial infarction (MI)) and . Pacing spikes are visible with what appear to be large, corresponding QRS complexes. You will also note that the underlying rhythm can be seen in the absolute refractory period of one of the (presumed to be) paced QRS complexes (red circle). WHEN ELECTRICAL conduction in your patient's heart is abnormal, transcutaneous pacing (TCP) can temporarily restore electrical activity. hyperkalemia, drug overdose), Avoid placing the pads over an AICD or transdermal drug patches, There is little data on optimal placement however, try to place the pads as close as possible to the PMI (point of maximal impulse) [1,2]. Transcutaneous pacing can be uncomfortable for a patient. Skin abrasions, the presence of a foreign body beneath the electrodes, sweating, and a high pacing threshold increase the patients pain and discomfort. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Transcutaneous Pacing Flashcards | Quizlet The device and the manufacturer's multifunction electrodes (MFEs) shown here are used to deliver TCP. The wire is secured with a loop of redundancy to the skin with sutures and occlusive bandage placed. PDF Transcutaneous and Temporary Transvenous Pacing 1999;17:10071009. [PMID:8558949], 2. 4=!vC x kuQ Med Biol Eng Comput. Transcutaneous Cardiac Pacing. Leong D, Sovari AA, Ehdaie A, et al. If time allows, obtain informed consent. Overbay D, Criddle L. Mastering temporary invasive cardiac pacing. Consider sedation for conscious patients unless they are unstable or deteriorating rapidly and pacing should not be delayed, turn on pacer and set the demand rate to approx. CrossRef Once the TPW has been positioned check stability by asking the patient to take deep 1983 Nov 10. 2004;24(3):2532. [Guideline] Glikson M, Nielsen JC, Kronborg MB, et al, for the ESC Scientific Document Group . J Cardiovasc Electrophysiol. Mechanical capture of the ventricles is evidenced by signs of improved cardiac output, including a palpable pulse, rise in blood pressure, improved level of consciousness, improved skin color and temperature. Europace. [QxMD MEDLINE Link]. If cardiovascular symptoms are not caused by the bradycardia, the patient may not improve despite effective pacing. The electrocardiogram of ventricular capture during transcutaneous cardiac pacing. ATRIAL THRESHOLD A preliminary report. x.,]+7%0:g&qET 8ix5?o eZ/Qn>HeyMn60mnGjhZ,w9_-N>nwd1Yh`TTv\5|Z Feldman MD, Zoll PM, Aroesty JM, Gervino EV, Pasternak RC, McKay RG. Classic false capture with near-vertical down-stroke of the (phantom) QRS complexes, slightly curved return to the isoelectric line, and unimpressive T-waves. The pacing electrode pads of an external pacing unit and locations in which each pad should be placed. The literature reports a wide range of sedation techniques and sedative agents. First human demonstration of cardiac stimulation with transcutaneous ultrasound energy delivery: implications for wireless pacing with implantable devices. Resuscitation. Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA, Department of Surgery, Oregon Health & Science University, Portland, OR, USA, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA, Allshouse, K.J., Musialowski, R.S. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 11921. You conduct appropriate assessment and interventions as outlined in the Bradycardia Algorithm. Appropriately used, external cardiac pacing is associated with few complications. Capture achieved at 110 mA confirmed with SpO2 plethysmograph, Pacing Artifact May Masquerade As Capture. Transcutaneous pacing electrodes (self adhesive gel pads frequently also used as defibrillator pads) are usually positioned in an anteroposterior configuration (see Fig. In contrast, true electrical capture will show wide QRS complexes with tall, broad T-waves. Recognition of a symptomatic bradycardia due to AV block is a primary goal. Sensing And Pacing Thresholds - Ventricular Pacing - Click to Cure Cancer Thomas James, Director of Customer Experience. Zagkli F, Georgakopoulou A, Chiladakis J. Content posted on this site is NOT medical advice and should not be used to treat patients or yourself. [QxMD MEDLINE Link]. Where should we email your 10% off discount code? Ettin D and Cook T.:Using ultrasound to determine external pacer capture. Conscious patients require analgesia for discomfort unless delay for sedation will cause/contribute to deterioration. When considering institution of transcutaneous pacing, always think about alternate causes for acute dysrhythmia, e.g. Pediatric and Adult Congenital Electrophysiology, Atrium Health Carolinas Medical Center, Charlotte, NC, USA, Sanger Heart and Vascular Institute of Atrium Health System, Charlotte, NC, USA, You can also search for this author in 14(2):137-42. The safety margin for transcutaneous pacemakers varies depending upon the specific device and patient. 1995;33:769. How to Calculate Margin of Safety | GoCardless 1986 Jan. 9(1 Pt 1):127-9. Strongly consider sedation, as external pacing can be quite uncomfortable. 1989 Nov. 12(11):1717-9. Transcutaneous pacing (TCP) is a difficult skill that is often performed incorrectly. [Internet]. 7 Steps to Calculate the Magin of Safety. %%EOF Do not be fooled by skeletal muscle contraction! 2014 Jun. Acad Emerg Med. Interventional Critical Care pp 191201Cite as. Figure Cautions for using TCP Watch for a change in your patient's underlying rhythm. BMJ Case Rep. 2018 Oct 2. When using external transcutaneous pacing, the conduction can fade with time; the pacer can stop working. It can be difficult to assess whether myocardial capture has been achieved; the surface electrogram and telemetry are frequently obscured by a large-amplitude pacing artifact, and palpation of the pulse can be . 2021 Aug 29. to perform CPR) during pacing. 8 0 obj Bradyarrythmia or bradycardia [terms are interchangeable]: Any rhythm disorder with a heart rate less than 60/min eg, third-degree AV block or sinus bradycardia. Transcutaneous Pacing is the use of electrical stimulation through pacing pads positioned on torso to stimulate contraction of the heart The current delivered in TCP is less than that used for cardioversion and defibrillation The stimulating current for TCP is milliamperes TCP indications Ideal current is 1.25x what was required for capture. Transcutaneous temporary pacing is mostly used as a "bridging" modality in emergency circumstances. Holger J S, Lamon R P, and Minnigan H J et al. Video courtesy of Therese Canares, MD; Marleny Franco, MD; and Jonathan Valente, MD (Rhode Island Hospital, Brown University). drop in blood pressure on standing (orthostatic hypotension), pulmonary congestion on physical exam or chest x-ray, bradycardia-related (escape) frequent premature ventricular complexes or VT, Present by definition, ie, heart rate less than 50/min. Cardiol J. [QxMD MEDLINE Link]. Studies have demonstrated that more than 90% of patients tolerate pacing for 15 or more minutes. (eds) Interventional Critical Care. Although transcutaneous pacing has been used continuously for as long as 4-5 days, [22, 23] the sites at which the pads are applied should be changed every 4-5 hours to reduce skin burn and discomfort. https://doi.org/10.1007/978-3-030-64661-5_18, Shipping restrictions may apply, check to see if you are impacted, Tax calculation will be finalised during checkout. Target rate is generally 60-80 bpm. The patient eventually expires from multiple-system organ failure. ACLS 2021 Flashcards | Quizlet % Malden: Blackwell Publishing; 2005. Document your patient's initial cardiac rhythm (including rhythm strip and 12-lead ECG if possible), the signs and symptoms that indicated his need for pacing therapy, the pacer settings (rate, current output, pacing mode), a cardiac rhythm strip showing electrical capture, the patient's pulse and BP, his pain intensity rating, analgesia or sedation provided, and his response. Ho JD, Heegaard WG, Brunette DD. Insert the transcutaneous pacing wire. (Threshold is the minimum current needed to achieve consistent electrical capture.)

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