If necessary, use clippers, scissors or a razor to quickly remove excess chest hair from the skin where the pads are applied
Ensure that the skin is dry
Use A-P positions for defibrillator pads if possible
If movement artefact appears to be inhibiting the pacemaker, switch the device to deliver fixed-rate pacing
Select an appropriate pacing rate (usually in the range of 60-90 beats/min). In some circumstances (e.g. complete AV block with an idioventricular rhythm 50 beats/min) a slower pacing rate of 40 or even 30 beats/min may be appropriate in order to deliver pacing only when required during sudden ventricular standstill or more extreme bradycardia
Warn the patient
Gradually increase the output while observing the patient and the ECG
As the current is increased the muscles of the chest wall will contract with each impulse and a pacing ‘spike’ will appear on the ECG
Increase the current until each pacing spike is followed immediately by a QRS complex, indicating electrical capture (typically a current of 50-100 mA)
In some circumstances when the need for pacing is urgent starting at the highest energy level and reducing until capture threshold is another method
Check the apparent QRS complex is followed by a T wave
Check that each paced QRS complex is followed by a palpable pulse (machanical response)
Set the output to 10mA (10%) higher than the threshold to ensure maintenance of capture
