# defibrillator implant malfunction



## Gbro (Jan 13, 2009)

What would you do if your pt's defibrillator implant delivers shock(s) and the monitor is showing NSR, Pt. is not showing any signs of poor perfusion? 

This is from an actual review. ALS please join in.


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## upstateemt (Jan 13, 2009)

I am a Critical Care EMT and an Electrophysiology Nurse. 

Sensing in an ICD can be turned of using a specially designed donut magnet (not just a simple pocket magnet).  The donut magnet taped over the device will open a reed switch and prevent sensing and thus preventing discharge.  

In the absence of the magnet (and not many ambulances carry magnets) the device will cycle through a pre programed number of shocks and then, hopefully stop.  

Single inappropriate shocks are not unusual, since the device is rate modulated something as simple as the patients heart rate going above the upper limit can initiate a shock.  A single shock, while uncomfortable, is nothing to worry about but the patient should be transported for evalualtion of the device to make sure that it doesn't happen again. 

I have had experience with one patient who was transported to the ER with a device that just kept shocking and shocking.  It recycled at the end of the event and started shocking again.  VERY SERIOUS.  In this paticular patient the device was removed and replaced, the patient recovered physically but emotionally he had a very difficult time.  

In the absence of the donut magnet there is not much a pre hospital care giver can do to stop inappropriate shocking.


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## KEVD18 (Jan 13, 2009)

Gbro said:


> What would you do if your pt's defibrillator implant delivers shock(s) and the monitor is showing NSR, Pt. is not showing any signs of poor perfusion?
> 
> This is from an actual review. ALS please join in.


 
reccomend they go to the hospital.
transport them if they agree.
doc a refusal if they dont.
have a coffee.


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## traumateam1 (Jan 13, 2009)

KEVD18 said:


> reccomend they go to the hospital.
> transport them if they agree.
> doc a refusal if they dont.
> have a coffee.



lol I'd like to see the person that doesn't wanna go to the hospital with that going on! :blink: I like the coffee part tho  

At my level, transport code 3 to the ER. Not much you can do other than that excpet O2, pain meds, and get ready for them to go into arrest? 

Sucky situation none the less, I remember seeing that on Paramedics I believe? Guys ICD kept going off every 15 or 30 seconds, and they couldn't get it to stop.


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## ffemt8978 (Jan 13, 2009)

upstateemt said:


> I am a Critical Care EMT and an Electrophysiology Nurse.
> 
> Sensing in an ICD can be turned of using a specially designed donut magnet (not just a simple pocket magnet).  The donut magnet taped over the device will open a reed switch and prevent sensing and thus preventing discharge.
> 
> ...



We have a patient in our area that this happens to quite frequently, and have received special permission to carry those magnets on our rig.  We are to call for online orders before we can use them, but I'm glad that our medical director is progressive enough to let us carry them.


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## upstateemt (Jan 13, 2009)

In this day and age where new protocols for Cardiac Patients have ICD's being implanted almost as frequently as PPM's and in many Cardiac Centers they are routinely implanted in any person who has a STEMI and and EF <30% the magnets should be on all ALS units and their use included in protocols. 

You can do no harm by applying a magnet to a monitored patient.  Should the pt go into VT with a magnet on it is simply a matter removing the magnet to allow the device to sense, charge and shock. 

I can imagine no more terrible an experience than repetative shocks.


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## reaper (Jan 14, 2009)

They are also needed in Pt's that have run away pacemakers! Our old service carried them on all trucks. I keep one in my back pack, just in case I need it on a call.


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## Gbro (Jan 14, 2009)

The round magnet,
Is this something that would be commonly found on an ALS Ambulance?

I remember 25>< years ago when my father-in-law got a pacemaker. He had to put on a wrist bracelet and put the phone handset into a modem and after a few min. place the doughnut magnet over the pacer to shut it off for more readings. It was that simple then, of course that was a pacer prior to implanted defibs, but what the hay?


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## upstateemt (Jan 14, 2009)

The magnet does not "shut off" a PPM, it simply reverts the settings to "factory" settings, usually a rat of 60-70.  Battery end of life can be determined by a "magnet test" as can thresholds and impedence. 

Think about it, if a magnet shut off a PPM, there would be a world of opportunity in the area of homocide

Magnets are not "standard" equipment, and I don't believe they should be.  Their use should be governed by Med Control and Protocol's.


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## reaper (Jan 14, 2009)

On a defib, the magnet will disable it. On a pace maker the magnet sends it into a default rate.


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## BossyCow (Jan 14, 2009)

So how do you know its a problem with the unit and not the pt? We've had this happen multiple times and its always an ALS call for us (if its available)


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## upstateemt (Jan 14, 2009)

Since the only way on knowing if it was the unit malfunctioning or the patient actually having VT of VF is to put them on a monitor it would have to be an ALS call.  

If only BLS were available there would be little that could be done except to monitor ABC's and transport quickly.


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## BossyCow (Jan 14, 2009)

upstateemt said:


> Since the only way on knowing if it was the unit malfunctioning or the patient actually having VT of VF is to put them on a monitor it would have to be an ALS call.
> 
> If only BLS were available there would be little that could be done except to monitor ABC's and transport quickly.



Absolutely, but the thread was posted to the BLS forum. So conversation about ALS interventions don't really apply do they?


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## upstateemt (Jan 14, 2009)

Well, the poster invited ALS comment. 


All BLS could do is care for the patient response and transport.


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## marineman (Jan 14, 2009)

ffemt8978 said:


> We have a patient in our area that this happens to quite frequently, and have received special permission to carry those magnets on our rig.  We are to call for online orders before we can use them, but I'm glad that our medical director is progressive enough to let us carry them.



That's a nice setup. Back before my time the ALS service I'm riding with was paged to a call for someone with a malfunctioning defib. Cardiac doc was in the ER when the page went out (all of our stations are at hospitals) and came running out to the rig with a magnet for the crew and told them to put it over the device. Ever since then our medical director has made them available in the ER that we can go and grab on the way out the door but we can't carry them on the rig. Don't really want to either between the 3 toughbooks and the monitor in the rig a magnet could cause a whole lot of problems.


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## Gbro (Jan 15, 2009)

BossyCow said:


> So how do you know its a problem with the unit and not the pt? We've had this happen multiple times and its always an ALS call for us (if its available)





> What would you do if your pt's defibrillator implant delivers shock(s) and the *monitor is showing NSR*, *Pt. is not showing any signs of poor perfusion?*



Could you please tell me what you do not understand here?


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## BossyCow (Jan 15, 2009)

Gbro said:


> Could you please tell me what you do not understand here?



Looking at a patient you describe can mean its the unit, or it can mean that the pt has an issue that I'm not able to see. Without a 12 lead and ALS, I cannot definitively determine that its an issue with the unit and not the pt. 

This was posted under BLS, and using BLS skills and tools, we can't make that determination. We can assume that its most likely to be the unit, but that would be a guess.


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## Gbro (Jan 15, 2009)

BLS Services in Minnesota have been using AED's w/monitors for many years. 
Basic Life Support is defined differently in some areas. Many places BLS is little more than a recumbent taxi service. Then there are progressive BLS services that *Have* to respond to everything called into 911. We don't cry out that we don't do those kinds of calls because, *We* are the only ones to do it. Thankfully the licensing agency is in harmony with this and allow BLS services to carry equipment and  1st line medications (nitro, glucagon,Ventolin inhalers, albuterol Nebulizers(SVN)etc) that are also carried on ALS units because ALS is not always available, or to distant. Sure we have lights and sirens, but that puts us all at risk.
Not everyone accepts this progressiveness in BLS.  but that's life! If you feel threatened by this, Maybe you need counciling? certainly you need Prayer?


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## BossyCow (Jan 15, 2009)

Gbro said:


> Not everyone accepts this progressiveness in BLS.  but that's life! If you feel threatened by this, Maybe you need counciling? certainly you need Prayer?



Never said I was threatened in anyway. Never said I had issues with it at all and I am in a very progressive, permissive BLS agency. But, even though an MPD allows a BLS agency to provide an ALS treatment, that doesn't make the treatment BLS. I am allowed to start IVs, give nitro, D50, glugagen, neb treatments, use combi-tubes etc.. but my agency is still only a BLS agency and has access only to a 3 lead. 

I guess my concern,is over the appropriateness of a discussion in a BLS thread, that advocates BLS agencies given the ability to shut off an implanted defib without adequate training and education in when it should be done and when it shouldn't. 

As for the prayers, I will always take all of those offered to me, but I think you assume a problem with me that is not supported by my signs and symptoms.. the same kind of situation I think may happen with your defib pt.


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## Gbro (Jan 15, 2009)

Dear Ms. B-C,

Your last responce was directed at me,


> As for the prayers, I will always take all of those offered to me, but I think you assume a problem with me that is not supported by my signs and symptoms.. the same kind of situation I think may happen with your defib pt.


However, I did not quote you, I was simply making a statement on this thread for the benefit of anyone reading (that includes you) as to why I posted this in the BLS forum. I am an EMT-B and will continue posting on the BLS forum. I will leave the ALS forum to them. I very rarely even look at the ALS forum.

I am quoting you now,


BossyCow said:


> Looking at a patient you describe can mean its the unit, or it can mean that the pt has an issue that I'm not able to see. *Without a 12 lead and ALS, I cannot definitively determine that its an issue with the unit and not the pt. *
> 
> This was posted under BLS, and using BLS skills and tools, we can't make that determination. We can assume that its most likely to be the unit, but that would be a guess.


Do you think it is nessesary to use a 12 lead to diagnose VT or VF?:unsure:
The AED uses 2 leads h34r:
Please don't intentional confuse the issue.

Have a nice day


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## BossyCow (Jan 15, 2009)

Gbro said:


> Do you think it is nessesary to use a 12 lead to diagnose VT or VF?:unsure:
> The AED uses 2 leads h34r:
> 
> 
> ...


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