High-fidelity simulation of transcutaneous cardiac pacing: characteristics and limitations of available high-fidelity simulators, and description of an alternative two-mannequin model.

Abstract

Transcutaneous cardiac pacing (TCP) is a potentially lifesaving technique that is part of the recommended treatment for symptomatic bradycardia. Transcutaneous cardiac pacing however is used uncommonly, and its successful application is not straightforward. Simulation could, therefore, play an important role in the teaching and assessment of TCP competence. However, even the highest-fidelity mannequins available on the market have important shortcomings, which limit the potential of simulation. Six criteria defining clinical competency in TCP were established and used as a starting point in the creation of an improved TCP simulator. The goal was a model that could be used to assess experienced clinicians, an objective that justifies the additional effort required by the increased fidelity. The proposed 2-mannequin model (TMM) combines a highly modified Human Patient Simulator with a SimMan 3G, the latter being used solely to provide the electrocardiography (ECG) tracing. The TMM improves the potential of simulation to assess experienced clinicians (1) by reproducing key features of TCP, like using the same multifunctional pacing electrodes used clinically, allowing dual ECG monitoring, and responding with upper body twitching when stimulated, but equally importantly (2) by reproducing key pitfalls of the technique, like allowing pacing electrode misplacement and reproducing false signs of ventricular capture, commonly, but erroneously, used clinically to establish that effective pacing has been achieved (like body twitching, electrical artifact on the ECG, and electrical capture without ventricular capture). The proposed TMM uses a novel combination of 2 high-fidelity mannequins to improve TCP simulation until upgraded mannequins become commercially available.