Compressions/Defibrillation considerations

[Wrar]

This has been a nuisance to me lately.

How do you treat patients with VAD, Pacemakers, Heart surgery that are about to have an imminent cardiac arrest?

1) for VAD, i heard that it pose a risk doing compressions? so if a Pt. is in Cardiac arrest we're not allowed to do compressions? if so then what is the best thing to do?

2) Where is the best place to put pads with patients who have pacemakers?

3) Also with Pts. who just had a heart surgery that is in Cardiac arrest do you just do cpr? wouldn't there be some considerations there too?

 

[DesertMedic66]

1.) may depend on your system as to what you do. For us here we do compressions on all VAD/LVAD patients unless they have a fully artificial heart. Otherwise contact the patients LVAD coordinator. A lot of LVAD patients have someone around them the majority of the time who is also trained in what to do and may help guide you.

2.) the majority of pacemakers are placed in the left upper chest so those don't interfere with pad placement. Otherwise place the pad below it or to the side.

3.) their heart is not beating. The only thing we have available is compressions.

 

[VentMonkey]

Thread bump...

After speaking with a good friend I decided to post this. I encourage any, and all EMS providers to add it to your phone.

It's free, updated frequently, and highlights the most common VAD's seen out there.

Peruse through it, and if you know of any VAD patient(s) in, or around your area don't hesitate to be familiar with their devices.

When all else fails ask them or their caretakers, and reference the phone number provided on their manual...

http://www.mylvad.com/sites/mylvadrp/files/Field Guides Master Document.pdf

 

[VFlutter]

Thread bump...

After speaking with a good friend I decided to post this. I encourage any, and all EMS providers to add it to your phone.

It's free, updated frequently, and highlights the most common VAD's seen out there.

Peruse through it, and if you know of any VAD patient(s) in, or around your area don't hesitate to be familiar with their devices.

When all else fails ask them or their caretakers, and reference the phone number provided on their manual...

http://www.mylvad.com/sites/mylvadrp/files/Field Guides Master Document.pdf

Awesome PDF!! Very thorough.

Oh and on a side note; Do not give heart transplant patients Atropine. Many people seem to forget that.

Being in a peri-arrest situation with a VAD patient is extremely difficult, especially in the prehospital setting. CPR is controversial and there is a risk of VAD cannula dislodgement however if you get to the point when you have exhausted all other options then you may not have a choice. Either way they are likely to have a poor outcome. Just make sure they are truly in cardiac arrest, since it can hard to obtain vital signs, and that you have done everything possible to get the VAD functional again.

VADs are preload dependent and may of these situations are caused by suckdown so volume resuscitation is key. Then standard ACLS; pressors, inotropes, and defibrillation.

More great info
http://emcrit.org/wee/left-ventricular-assist-devices-lvads-2/

 

[NomadicMedic]

@VentMonkey, I should post what prompted this ...

 

[VentMonkey]

@VentMonkey, I should post what prompted this ...

By all means, brutha...

 

[NomadicMedic]

So far today I've only run one call, but it had a bit of pucker. 68yo guy at the landfill, dumping his yard debris. His son calls 911 and says, "I think he's having a heart attack". We're about 15 minutes from the scene. Dispatch advises his AICD has discharged twice. A few minutes later, "be advised, he also has an LVAD"

He did not have any info or an LVAD card. No details on the LVAD nor was he forthcoming about much of anything. He was conscious and alert and terrified that he was going to get lit up again.

Here's the best part. He's normally seen in Atlanta, 4+ hours from me. We were <10 minutes from the community hospital and probably close to an hour from the nearest ER that takes cardiac cases.

I called the doc at the local ED and said, "look, this guy is a hot mess and I'm bringing him to you." He was like, "uhhh...okay. If you have to"

I don't get really nervous on most calls, but I was actually afraid he was going to code on the way to the cardiac capable ER and I'd be stuck in the back with this dying guy with no help and no way to really help him. Oh yeah, He had no veins to speak of and I wasn't going to tear up what he had unless I really needed to. So, no access. (I had the drill sitting next to me on the bench)

En route, I didn't do anything except say, "hey dude, don't die." He didn't. I put him on the ER bed and GTFO.

Monitor: sinus tach at 110 with occasional PVCs.

Another life saved. Not today reaper. Hahahah

 

[VentMonkey]

CPR is controversial and there is a risk of VAD cannula dislodgement however if you get to the point when you have exhausted all other options then you may not have a choice. Either way they are likely to have a poor outcome. Just make sure they are truly in cardiac arrest, since it can hard to obtain vital signs, and that you have done everything possible to get the VAD functional again...VADs are preload dependent and may of these situations are caused by suckdown so volume resuscitation is key. Then standard ACLS; pressors, inotropes, and defibrillation

These devices are so case specific, and still somewhat infrequent, though I don't doubt that won't change soon enough.

We were pretty much taught this in my CCP course. Not to take away from this thread, but for any paramedic, or RN interested in critical care, this course tops my list.

It was 5 months of topics such as this aimed at critical thinking, deeper pathophysiology, discussion boards aimed at rationalizing and problem solving, and an excellent resource for anyone interested in the clear between in-hospital and prehospital critical care medicine, be it ground or flight.

 

[MonkeyArrow]

So far today I've only run one call, but it had a bit of pucker. 68yo guy at the landfill, dumping his yard debris. His son calls 911 and says, "I think he's having a heart attack". We're about 15 minutes from the scene. Dispatch advises his AICD has discharged twice. A few minutes later, "be advised, he also has an LVAD"

He did not have any info or an LVAD card. No details on the LVAD nor was he forthcoming about much of anything. He was conscious and alert and terrified that he was going to get lit up again.

Here's the best part. He's normally seen in Atlanta, 4+ hours from me. We were <10 minutes from the community hospital and probably close to an hour from the nearest ER that takes cardiac cases.

I called the doc at the local ED and said, "look, this guy is a hot mess and I'm bringing him to you." He was like, "uhhh...okay. If you have to"

I don't get really nervous on most calls, but I was actually afraid he was going to code on the way to the cardiac capable ER and I'd be stuck in the back with this dying guy with no help and no way to really help him. Oh yeah, He had no veins to speak of and I wasn't going to tear up what he had unless I really needed to. So, no access. (I had the drill sitting next to me on the bench)

En route, I didn't do anything except say, "hey dude, don't die." He didn't. I put him on the ER bed and GTFO.

Oh yeah, sinus tach at 110 with occasional PVCs.

Another life saved. Not today reaper. Hahahah

This would probably be a good indication to fly him out, if that option was available to you.

 

[VentMonkey]

This would probably be a good indication to fly him out, if that option was available to you.

Not steal @DEmedic's thunder, but I believe the patient may have been.

 

[NomadicMedic]

Not steal @DEmedic's thunder, but I believe the patient may have been.

Yep. That was the thought process. Get him to the local ED where he can be managed/stabilized if needed and then flown out. (Which is what was happening when I left)

 

[VentMonkey]

Yep. That was the thought process. Get him to the local ED where he can be managed/stabilized if needed and then flown out. (Which is what was happening when I left)

Sounds like the right call in my book.

 

[phideux]

Yep. That was the thought process. Get him to the local ED where he can be managed/stabilized if needed and then flown out. (Which is what was happening when I left)

WE have a local Boo-Boo station ER, but they got a nice Heli-Pad. Spent quite a few times in the parking lot waiting on the chopper. We had some issues with the ER folks there complaining about some of the patients we brought there, or tried to bring there. I think it pissed them off worse though when we would use their Pad to fly patients out but didn't bring them in so they could "assess" them.

 

[Carlos Danger]

It was 5 months of topics such as this aimed at critical thinking, deeper pathophysiology, discussion boards aimed at rationalizing and problem solving, and an excellent resource for anyone interested in the clear between in-hospital and prehospital critical care medicine, be it ground or flight.

Which course was that, specifically?

 

[VentMonkey]

Which course was that, specifically?

https://ems.creighton.edu/training-certification/critical-care-paramedic

 

[Underoath87]

3) Yes, you do regular compressions on patients with a recent heart transplant. Just try not to overdo it and go all "Temple of Doom" on them

 

[VentMonkey]

3) Yes, you do regular compressions on patients with a recent heart transplant. Just try not to overdo it and go all "Temple of Doom" on them

Nice analogy. Also, I would forego Atropine on these patients specifically, though I guess most patients nowadays don't get it anyhow.

 

[Summit]

3) Also with Pts. who just had a heart surgery that is in Cardiac arrest do you just do cpr? wouldn't there be some considerations there too?

There are considerations for open heart surgery, by which I mean cases when a sternotomy was performed as part of the heart surgery. Usually this won't be a worry for EMS unless you are doing a CCT IFT.

In CTICU we are going to try pacing/defib and drugs (no epi!) BEFORE CPR, maybe as far out to about post op day 10. We have stories of jumping on responders in order to stop them from starting compressions.

Basically, fresh open heart surgery arrest:
VF/VT, we do stacked shocks, amio if its handy
Asystole (or profound brady) we pace and give atropine (unless it was a transplant)
PEA skip to CPR (unless you think it is tamponade or massive hemorrhage where you can instantly intervene)

THEN, if NO ROSC, THEN you can do CPR, but that is just a bridge to resternotomy. We are opening the chest STAT STAT (we say less than 5 minutes). We are doing it right there in the ICU bed. Open cardiac massage and putting little paddles right on the heart are options here as well as relieving tamponade. Emergent resternotomy at the bedside is intense. It is different than clamshelling a trauma arrest like you might have seen in the ED (that is also intense). If you get ROSC, then they go to the OR.

CTICU has a premade procedure cart exclusively for emergency resternotomy at the bedside.

Do know this for prehospital: if you do CPR on a relatively fresh open heart patient, you have probably committed to resternotomy. The clock is ticking and consider facility capability since most facilities do not have CT ICU/Surg. In addition to the trauma normally encountered from CPR, the heart has easily damaged fresh surgical grafts/implants and the sternum was cut and put back together with wires.