title: Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a systematic review.
abstract: BACKGROUND
  Advanced cardiac life support (ACLS) guidelines suggest transcutaneous cardiac pacing (TCP) for the treatment of symptomatic bradycardia (SB) and bradyasystolic cardiac arrest (BACA). Many EMS systems are extrapolating these guidelines and employing TCP in the prehospital setting. Our objective was to conduct a systematic review to determine the efficacy of prehospital TCP in the management of these two conditions.
  
  
  METHODS
  MEDLINE (1966-2004), EMBase and Science Citation Index (1980-2004) were searched using: prehospital/emergency medical services; external/transcutaneous; pacing. Two reviewer teams blinded to the source and author conducted a hierarchical selection (title, abstract, article) and quality assessment using a validated scale. Kappa agreement at each level of review was measured. Data abstraction was done by consensus.
  
  
  RESULTS
  Thirty-four articles were identified and seven selected (Kappa agreement; title: 0.85, abstract: 0.78, full article: 0.82). Article quality was poor in all trials. There were three case series (BACA, n=215), three unblinded randomised controlled trials (one BACA, two BACA+SB), and one subgroup (SB) analysis. In the case series of paced BACA patients, 0/215 survived to hospital discharge. In the BACA trials 16/509 (paced) versus14/497 (control) survived to discharge. In a subgroup of one SB trial 5/6 (paced) versus 1/7 (control) survived to discharge (p=0.01). When a SB trial subgroup was combined with a case series 4/27 (paced) versus 0/24 (control) survived to discharge (p=0.07).
  
  
  CONCLUSIONS
  In the prehospital setting, there is no evidence to support the use of TCP in bradyasystolic cardiac arrest. There is inadequate evidence to determine the efficacy of prehospital TCP in the treatment of symptomatic bradycardia.
authors.affiliation: Division of Emergency Medicine, Department of Medicine, University of Toronto, and Sunnybrook Osler Centre for Prehospital Care, Toronto, Ont., Canada.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Sherbino
authors.forename: P Richard
authors.initials: PR
authors.lastname: Verbeek
authors.forename: Russell D
authors.initials: RD
authors.lastname: MacDonald
authors.forename: Bruce V
authors.initials: BV
authors.lastname: Sawadsky
authors.forename: Andrew C
authors.initials: AC
authors.lastname: McDonald
authors.forename: Laurie J
authors.initials: LJ
authors.lastname: Morrison
mesh_terms: D001919:Bradycardia / Q000150:complications / Q000628:therapy*; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D004632:Emergency Medical Services; D004638:Emergency Treatment; D006323:Heart Arrest / Q000150:complications / Q000628:therapy*; D006801:Humans; D013599:Systole