LVAD: do you know enough?

29 Sep

Raging Hypothetical:

You are working overnight in a single coverage emergency department and the next patient walks in with a wire hanging from his chest and no palpable pulses. He needs help because the alarm on his device is going off. You look at the external device and it reads “low volume”. Before you start to treat this patient, a few important things to keep in mind…

 

Who gets LVADs?

Severe heart failure

EF <25%

VO2max <15

And a few other less common criteria

 

What in the world is it?

LVAD = Left Ventricular Assist Device 

=An external pump unit outside the body with an intake channel (draining blood from the left ventricle) and output channel (ejecting blood into the aorta)

 

Why might these patients come into the ED?

Infection of the driveline at skin insertion site

Bleeding (these patients are anticoagulated while using this device)

Hypovolemia

Pump thrombosis

Machine alarming

Patient is coding or pump not running (this is pretty much the same thing)

 

What to do?

All situations:

-contact the patient’s VAD coordinator

-listen over the heart to hear if the monitor is working (sounds like a “muffled blender”)

-evaluate mental status, skin color for perfusion, skin driveline site for infection

-evaluate the machine for battery function, lines plugged in, alarms of “low flow” or “low volume”

MAP should be 65 on manual Doppler (automated cuffs less accurate)

EKG to look for RV problems, arrhythmia, STEMI

-consider beside echo to assist with your differential (heart failure, focal wall motion abnormality, PE, etc.)

 

The patient should have extra batteries or there should be a special power pack option to plug into the wall

 

VADs love volume! Fluid bolus if poor perfusion, give PRBC if bleeding, but… think twice about correcting elevated INR or reversing coumadin (is this worth clotting off the patient’s device???)

 

Consider inotropes. Right heart failure à dobutamine; sepsis or reduced afterload à norepinephrine

 

Signs of pump thrombosis à hot device, working hard with high RPM, dilated RV/LV on bedside echo, low MAP. Consider heparin bolus.

 

And for the coding patient… avoid CPR. You can rip out the driveline. Yikes! But use your clinical judgment. The patient may need CPR if the pump is not working and the patient has lost their BP (MAP = zero).

 

Submitted by K Estes.

 

Sources: EMCrit Blog, EM:RAP podcast; picture

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