I would recommend temporarily disabling tachy therapy with a ring magnet to see what you've got and allow the underlying rhythm to stabilize since repeated ICD shocks can irritate the heart. Make sure you're dealing with ineffective ICD shocks as opposed to inappropriate ICD shocks (either way I would apply a ring magnet). Most common reason for inappropriate ICD shocks is AF. Since heart failure with low EF is an indication for an ICD and AF and bundle branch blocks frequently accompany heart failure, wide and fast rhythms will often be associated with ICD shocks whether it's true VT or not which can make this confusing to deal with. Just remember Einstein's definition of insanity (doing the same thing over and over and expecting a different result). If shocks 13, 14, and 15 didn't convert the rhythm (or the rhythm keeps going back into VT) then what makes you think shocks 16, 17, and 18 will do the trick? ICD shocks are not benign events. They traumatize the patient and they deplete the battery life of the device. So if you wouldn't shock it over and over, you probably shouldn't let the ICD shock it over and over. That's assuming you carry a ring magnet and have a Medical Control Physician who supports its use (which often isn't the case since many emergency physicians aren't comfortable with these situations either). I would customize therapy to the underlying problem. For example, if the patient is hypokalemic and has a prolonged QT-interval that is triggering runs of Torsades, the shocks aren't going to work until the electrolyte problem is fixed. For the recent case a paramedic in my department dealt with, the ICD was disabled in the field (which stabilized the rhythm) and amiodarone was given in the emergency department. If you don't carry a ring magnet then consider sedating the patient like TOTWTYTR did for his patient. That may be the most humane thing you can do under the circumstances (along with treating the underlying problem with an appropriate antiarrhythmic).
Tom
