LVADs

[wrmedic82]

I just ran my first call with a Pt with an LVAD which I thought at the time was cool as hell. Especially when asking my rookie emt to check a BP. But with anything comes a lil humility as many thoughts raced through my head after the call. Realizing I really don't know anything except lil bits and pieces, I was hoping someone could give me some insight on these devices, potential problems and how to best manage the Pt should the device fail other than cpr. Would ACLS even be effective for these Pt's? Any insight would be appreciated.

[MariB]

Lvads have a manual over ride pump you can use in case of mechanical failure . I was taught that in EMT b believe it or not

Usually your best bet if possible is asking the patient or family as they are best educated hoping they are available to answer.

[paramedicmike]

Which device did your patient have? There are a couple out on the market. The Heartmate II is the one I've encountered.

Once an LVAD is in place, CPR is out. Start compressing with this thing and you'll dislodge the tubing leaving a gaping hole in the LV. Generally, should it fail there may be a hand crank (not joking) to keep the device operational.

Checking vitals gets tricky. The patient may or may not have a palpable pulse.

As with many specialized treatments/devices your patient and his/her family members should prove to be a wealth of knowledge regarding the condition/device s/he has. My experience has been that the patient usually loves to talk about it. All you gotta do is ask.

I found this, too. It's 20 pages long but it looks to be a good information packet.

Edit: Some device may have a hand crank. Not all of them will.

Edit #2: Your patient should have an LVAD coordinator at the hospital that implanted the device. The coordinators LOVE when EMS calls to get information about a device. Seriously! They really do love it! Find out who the coordinator is and talk to him/her. You may even be able to arrange a training session. If this patient lives in your local it behooves everyone in your service to know what's what.

Apologies for the scattered post.

Edited July 30, 2013 by paramedicmike

[wrmedic82]

Thanks for the advice gives me a starting point to learn more

[Mateo_1387]

There have been LVAD patients in multiple districts I have been positioned in. I have never had the pleasure of interacting with one of these patients though. It was required for me to take a class about the LVAD, which consisted of a representative from the manufacturer, an RN I think, to give a lecture to us. It was quite informative. I will endeavor to relay that information to you, though suggest you confirm the information, as I really do not have a source for the information. Anyways here goes...

When trouble shooting a problems, as others have echoed, and as the link Mike shared, use the family, call the coordinator, but be humble that you may not be the most knowledgeable about how the device works. Know though that a common alarm is a low flow alarm. Apparently, these patients often are dehydrated and may benefit from a fluid bolus. High blood viscosity can cause a low flow issue, thus fluids may help dilute the blood the promote circulation.

There are three other "common issues" these patients may have along with the dehydration. Frequently LVAD patients are prone to stroke, Gastrointestinal Bleeds, and infection. I think some of these are self explanatory, such as stroke being due to the "thick" blood, probably clotting issues from trying to repair the surgical implants and permanent body openings (I'm really guess on this one, maybe someone else knows better than I). GI bleeds make sense to me as these patients will also be placed on anticoagulant therapy. Infection due to insertion site of the LVAD.

As said before, no CPR.... But everything else can be done. These patients can receive all ACLS drugs and they may be defibrillated/cardioverted. Keep in mind theses patients have failing hearts and are usually waiting for a transplant. We were warned in class to not be surprised that a patient may present with things such as ventricular fibrillation and lethal heart rhythms, though are still able to communicate (though will likely be weak and have poor circulation). Also, keep in mind the patients are prone to have medical problems not related to the LVAD, so do not let it be a distraction during a differential workup.

I hope this is helpful, I have tried to recall some of the more important information I remember from the class. It may be beneficial if your agency and local hospital (mostly emergency room staff) can put together a few classes with a representative from the LVAD community. Again, I suggest you confirm my information, as its not from a specific source, and some of the information may have changed by now, as I took the class a few years ago. If anyone knows better, please do not hesitate to correct me. I'd benefit from it too.

Anyways, one last note, speaking of asking your coworker to take a blood pressure... I always enjoy going to a class and hearing someone say in reference to ventricular fibrillation "they won't be talking to you"... I usually comment back "well... if the patient has an LVAD, they might be talking to you".... Always looking for the exception to a rule...

Matt

[triemal04]

The above posts are pretty spot on, so just a couple points.

Hypovolemia (often due to dehydration) is the most common problem, and will often not present as such. Unless there are contraindications, judicious fluid boluses are often a good idea.

You CAN obtain a BP, though you won't hear normal sounds, but a "whoosh" (that really is the best description) and what you are getting is actually the MAP.

If a patient is conscious and in vf, this is not "acceptable" just because they have an LVAD. Though these devices can, and sometimes do function as the only means of moving blood, they are not designed to; it's called a left ventricular ASSIST device for a reason. Something has gone wrong with your patient, and it needs to be treated.

Beyond talking with a coordinator if you aren't certain about what to do, take the patient to the hospital where they are followed, even if it's for a problem you see as routine, and unrelated to their LVAD. If it's a longer drive...tough nuts.

There are some devices that don't have ANY sort of way to manually activate them. Definetly look for a way, but realize there may not be one.

Don't forget to check the battery life before you leave, and if the patient is capable of changing it, get a lesson on how to do so before you are on the road. (or failing that, take that person with you.)

[chbare]

Just wanted to add that if you transport a patient, make sure you transport all of the equipment for the VAD including the power base unit (PBU).

[island emt]

We encountered a gentleman from out of state 6 years ago with an LVAD. They were here for the summer and called me to make us familiar with the device, his medical HX and how to get more info from his clinical co-ordinator down in Boston. I went to meet with him & his wife, it's kind of scary when you check for a pulse and there really isn't one while talking to him. You could feel a slight pressure wave peripherally , but it was stronger at the carotids.

He had a base power unit and three backup batteries for traveling. Called the care co-ordinator who faxed me all sorts of info on that particular unit and how to troubleshoot problems.. Biggest thing was if pt is in distress transport them on to the big city hospital an hour & 1/2 south where they could care for him and not stop at the local ER as they are not capable of dealing with the equipment.

the pt did call us for assistance one time during an extended power failure and we brought him to the station so he could plug in to our generator power and get all his batteries recharged. other than that no issues. Last I knew he was still on a transplant list.

[jwiley40]

I transported a patient with an LVAD. Hers began slowing to the point of syncope. Interesting device! My wife (CV ICU RN) guided me through all of the little idioscracies of the device. She asked me if I was able to hear lung sounds. No, all you hear is pump buzzing. I took my V/S with my monitor and decided that since they looked odd, to do manual V/S checks. Nothing was right. I decided to stay with manual because at least I knew those would be accurate.

I was never taught about those devices. I have found that much of my training has been void of necessary information and knowledge. So, my advice to anyone that sees something they have never seen before, look at it, ask questions, research it and don't be afraid to be a little nosy. Hell, it's what we get paid for anyway, right?

[AnthonyM83]

Could you be more specific? "What you are getting is actually the MAP"?

The MAP is usually a single number, and when you take a blood pressure it gives two numbers...which is the MAP

The above \

You CAN obtain a BP, though you won't hear normal sounds, but a "whoosh" (that really is the best description) and what you are getting is actually the MAP.

Also, there should be a phone number on the device with a 24-hour support line that can lead you through working any cardiac arrests or critical situations with these patients. They're your best bet!