Patients who present with the above arrythmias accompanied by hypotension and or signs of poor perfusion including syncope, altered mental status, signs of end organ ischemia such as angina warrant immediate intervention. If time and resources permit, a trial of pharmacological intervention is reasonable with a low threshold to progress to or add cardiac pacing. Drug therapies may include anticholinergic drugs such as atropine, or inotropes and chronotropes such as epinephrine or dobutamine, however do not delay initiation of cardiac pacing if medication is not readily available, or there is a lack of response to medication.

Cardiac pacing can be performed transcutaneous, through externally applied pacing pads, transvenous, via a central venous catheter serving as an introducer for a pacing wire that is floated through the venous system into the heart, or via epicardial leads that are placed surgically. Each application will be discussed below. Cardiac pacing is a temporary measure, designed to buy time for treatment and intervention, such as cardiac catheterization or electrophysiology studies, resolution of the underlying cause, or until definitive intervention, such as placement of a permanent pacemaker.

Pacing capabilities are depending on the echelon of care the patient is being retrieved from and can also be influenced by resource and conflict scale variables as well. CCATT and Aeromedical Evacuation (AE) teams do not have the capability to place transvenous pacers, however they should certainly be familiar with patient management, troubleshooting, and contingency plans, like transcutaneous pacing via appropriate flight approved equipment. Patients requiring cardiac pacing should be triaged as at urgent for patient movement as definitive care is usually not available until Role 3 facilities or higher. Besides familiarization with this CPG, augmenting the patient care team with a member who is familiar and comfortable with cardiac pacing and troubleshooting is advised if possible. If not, it is reasonable to call the ADVISOR hotline at 1-833-ADVSRLN (1-833-238-7756 or DSN 312-429-9089) to speak with a cardiologist for further guidance and support.