Pace judgement - when slow is too slow. Trans-venous pacing (TVP) in the aeromedical retrieval environment
BPhEd, MBChB, FACEM, PGCertAME, DipIMC & DipRTM(RCS Ed), GCertCU
Stefan is a PreHospital and Retrieval physician and Medical Retrieval Consultant in South Australia with the state based retrieval service, SAAS MedSTAR, and is the Head of Unit, Training and Education for the service. Stefan also works as an Emergency Physician in the Royal Adelaide Hospital Emergency Department.
Stefan has worked previously in Wellington, Perth, Birmingham, Auckland, Sydney, Townsville and London. His introduction to retrieval was undertaking paediatric and neonatal retrievals for NETS in Sydney, New South Wales, and subsequently he had PreHospital and Retrieval roles with Mediflight in South Australia, for CareFlight in Queensland where he was also the Director of Training and Education and spent a period in London working for London HEMS in PreHospital trauma care.
Stefan has an academic position at the School of Public Health at James Cook University and is an examiner in retrieval medicine for the Royal College of Surgeons in Edinburgh. He has published various papers and textbook chapters on prehospital care and disaster medicine, primarily looking at the role of prehospital ultrasound.
Bradycardia can be a complication in a range of emergency diagnoses including myocardial infarction and drug poisoning. If left untreated, bradycardia can lead to inadequate cardiac output and poor organ and tissue perfusion. Although some patients may respond adequately to pharmacological therapy, many don’t and require temporary cardiac pacing. Whilst transcutaneous pacing (TCP) is generally quick and easy to apply, it is often poorly tolerated, requiring sedation and analgesia which can cause further physiological compromise in a patient who may already be hemodynamically challenged. Trans-venous pacing (TVP), using a pacing wire placed in the right ventricle, is generally better tolerated patients, doesn’t require sedation and capture is more reliable resulting in more effective cardiac pacing.
Patients with symptomatic bradycardia in regional, rural and remote areas of Australia will usually require transport to a major referral centre. As a consequence medical retrieval teams may need to institute temporary symptomatic management, including cardiac pacing, until they can reach a hospital that can provide definitive treatment or their underlying pathology has been rectified. This often means being transported over a range of distances using a range of transport modalities.
SAAS MedSTAR, the South Australian Emergency Medical Retrieval service, has been initiating and transporting patients on TVP for many years. This presentation will describe the SAAS MedSTAR approach to initiating TVP in the retrieval environment and report the success rate, clinical features, short term complications, and outcomes for all the TVP cases done by SAAS MedSTAR in the 2 year period 2016 and 2017.
We have been able to find very little in the medical literature regarding the initiation of TVP by prehospital and retrieval teams and this presentation and subsequent publication will help to build the evidence base around the feasibility of this procedure for medical retrieval services.