CASE REPORT
Providing emergency care for patients with ventricular assist devices Valesia Henriques, MS, PA-C; Rahul Sharma, MD, MBA, FACEP
CASE A 23-year-old man presented to the ED complaining of brown, watery, nonbloody diarrhea and generalized fatigue for the past 2 days. He has a history of viral cardiomyopathy and received a left ventricular assist device (LVAD) about 1 year ago after an unspecified viral illness. He reports no problems with the LVAD since its implantation. He denies any recent travel or sick contacts, recent antibiotic use, melena, fevers, chills, chest pain, shortness of breath, palpitations, or abdominal discomfort. The remainder of his review of systems is negative. Physical examination The patient is a well-appearing black man in no acute distress. His vital signs are: BP via Doppler, 80 mm Hg sitting, 70 mm Hg standing, and 74 mm Hg lying down; heart rate, 76; temperature, 36.8° C (98.2° F); respirations, 20; and Spo2, 96% on room air. His skin is warm and dry; his pupils are equal, round, and reactive to light and accommodation; and his mucous Valesia Henriques practices in the ED at New York University’s Langone Medical Center in New York City. She completed a PA residency in emergency medicine at New York Presbyterian HospitalWeill Cornell Medical College in New York City. Rahul Sharma is executive vice chief of emergency medicine and an assistant professor at New York Presbyterian Hospital-Weill Cornell Medical College. The authors have disclosed no potential conflicts of interest, financial or otherwise. Acknowledgment: The authors would like to thank Lauren Krinsky, NP, VAD coordinator at NYU Langone Medical Center, for her help with this manuscript. DOI:10.1097/01.JAA.0000464278.21246.14 Copyright © 2015 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
0515 JAAPA_CR_OL_VADs_Puneet.indd 1
COURTESY OF THE NATIONAL INSTITUTES OF HEALTH
ABSTRACT Emergency medicine clinicians who care for patients with ventricular assist devices (VADs) must have basic knowledge of the device mechanics, population-specific patient assessment techniques, and specific hospital recommendations for care of these patients. This case report illustrates a systematic approach that can be used in the ED for evaluating patients with VADs. Keywords: ventricular assist device, emergency, patient assessment, nonpulsatile blood flow, dehydration, malfunction
FIGURE 1. Left ventricular assist device
membranes are dry. Neck examination shows no jugular venous distension. A “whirling” sound is heard with cardiovascular auscultation, and his lungs are clear to auscultation. His abdomen is soft and nontender with normal bowel sounds. He has no calf tenderness or lower extremity edema bilaterally. A neurologic examination is nonfocal. A clean driveline extends from the left upper quadrant of the abdominal wall to a controller located at the patient’s waistline. A green light illuminating on the controller indicates that the controller is receiving power. Two power cables extend outward on each side and connect to battery power or AC power. The lines are connected to a battery pack located on each side of the patient’s waist. (For more about VADs, see Figure 1). Laboratory and diagnostic testing An ECG shows a normal axis, normal intervals, and no ST-segment changes. A chest radiograph ordered to assess for percutaneous lead placement and fluid overload is interpreted as normal. Laboratory tests including electrolytes, complete blood cell count, coagulation factors, brain natriuretic peptide, lactate, and troponin are within normal limits. Management and treatment Upon ED arrival, the patient was placed on a cardiac monitor, vital signs were obtained, two peripheral IV devices were placed, and the VAD team was consulted. After further exploration of the patient’s presenting signs and symptoms, he was given IV fluids for dehydration. The patient remained under observation in www.JAAPA.com
03/04/15 12:47 PM
CASE REPORT
Key points Always start the clinical assessment with the ABCs. Common reasons for patients with VADs to present to the ED include device malfunction, infection, dehydration, myocardial infarction, thrombosis, and cerebrovascular event. Contact the facility VAD team or representative center as soon as possible to facilitate care planning. CPR may cause fatal hemorrhaging in patients with VADs and should only be used as the last lifesaving measure in these patients.
the ED for the next 4 hours and was ultimately diagnosed with dehydration secondary to diarrhea, cleared for discharge by the VAD team with care recommendations, and advised to follow up on an outpatient basis. DISCUSSION A VAD is a mechanical device that is surgically implanted into the patient’s chest and augments cardiac output. VADs can be a bridge to transplantation or destination therapy. Patients with VADs may be adequately treated and evaluated in the ED using a systematic approach that starts with the ABCs (airway, breathing, and circulation) and focuses on evaluating the entire patient, not just the implanted device. Providers should know not to use BP cuffs in patients with VADs, as a pulse often is undetectable. Order essential laboratory and diagnostic tests, including a complete blood cell count, basic metabolic panel, cardiac troponins, and B-type natriuretic peptide level; initiate resuscitation; and contact the appropriate facility VAD team or representative. In patients with VADs, arterial BP is most reliably assessed using a manual Doppler. Most VADs use continuous flow technology, resulting in a continuous, nonpulsatile blood flow. Because patients do not have a palpable pulse, taking BP with a manual cuff and stethoscope will not give accurate results. Instead, use a manual Doppler to obtain an accurate arterial BP, and pay special attention to the patient’s mental status and skin and lip color when assessing oxygenation level. During resuscitation, the goal is to maintain the mean arterial BP in the range of 70 to 80 mm Hg.1 This may be accomplished with vasoactive medications, inotropic medications, or intravascular fluid volume management.1 Respiratory rate and temperature may be obtained in the same manner for patients with or without VADs. However, pulse oximetry may be unobtainable and unreliable in patients with VADs because of diminished pulse pressure.1 A modified version of the primary survey can be used to establish a general clinical impression of the patient and the patient’s perfusion status. For patients responsive to verbal or painful stimuli, determine if the patient’s airway www.JAAPA.com
0515 JAAPA_CR_OL_VADs_Puneet.indd 2
is patent and intervene if necessary with supplemental oxygen, bag-valve-mask assistance, or endotracheal intubation. Use patients’ skin color and feel as an indicator of circulation. If the patient is unresponsive, immediately assess for a pulse and auscultate over the anterior chest for a “whirling” sound. Remember that some implanted fully functioning LVADs providing continuous flow do not provide the patient with a palpable pulse because of reduced pulse pressure. Initiating CPR in patients with VADs is controversial and site-specific; refer to the facility’s recommendations. In pulseless patients with VADs, providers should use every adjunctive resuscitation modality, including fluids, antiarrhythmics, vasoactive agents, and/or inotropic medications before initiating CPR. If the “whirling” sound of the motor can be heard during auscultation, CPR should not be initiated because the force of adequate compressions may irreversibly damage the device or cause fatal hemorrhage. CPR in a patient with a VAD is indicated if the patient is pulseless, unresponsive, and the device is not functioning (no “whirling” sound during auscultation). Due to the risks, CPR should be a last resort for resuscitation. Common reasons for patients with VADs to present to the ED include infection, device alerts or malfunction, bleeding, cerebrovascular events, dehydration, trauma, thrombosis, myocardial infarction, dysrhythmias, and right heart failure. A high index of clinical suspicion in these patients will prevent missed cases of potentially fatal clinical diagnoses.
Patients with VADs can become dehydrated because they tend to limit their oral intake and are on a salt-restricted diet. Infection Erythema or drainage from the driveline site should immediately prompt an investigation for causes to rule out sepsis. If the patient’s vital signs are unstable or if the patient is tachycardic, hypotensive, or febrile with or without a known source of infection, treat the patient for sepsis. Focus on maintaining volume status without causing volume overload. Device alerts or malfunction Alerts that may prompt patients to present to the ED include loss of power to the pump, for example, from disconnecting both power leads simultaneously or disconnecting the percutaneous lead from the controller.1 Bleeding Most if not all patients with VADs are on anticoagulants to keep their international normalized ratio between 2 and 3. Across studies, the most commonly Volume 28 • Number 5 • May 2015
03/04/15 12:47 PM
Providing emergency care for patients with ventricular assist devices
reported sources of bleeding are epistaxis, GI tract bleeding, bleeding within the mediastinum and thorax, and intracranial hemorrhage.2 In patients with VADs who present with unstable vital signs, altered mental status, or complaints of dark stools, rule out a hemorrhagic process. Cerebrovascular events If the patient presents with symptoms that are concerning for a stroke, consult neurology and obtain a head CT to rule out intracranial hemorrhage or infarct. Dehydration Cardiac devices need volume to function properly. Patients with VADs can become dehydrated because they tend to limit their oral intake and are on a salt-restricted diet.1 However, as part of the differential diagnosis, also consider conditions that reduce the return of blood to the left ventricle, such as right ventricular failure, cardiac tamponade, and pulmonary hypertension.1 Once the possibility of device malfunction, myocardial infarction, infection, and neurologic compromise has been excluded, a diagnosis of dehydration can be entertained and the patient can be given adequate fluid resuscitation. Contact the VAD team as soon as possible. The initial contact person typically is a nurse practitioner or physician assistant (the rest of the team consists of cardiac surgeons, cardiologists, case managers, social workers, and other
JAAPA Journal of the American Academy of Physician Assistants
0515 JAAPA_CR_OL_VADs_Puneet.indd 3
support staff). Most patients will have a detailed medicalalert bracelet or a tag on the controller around their waist that lists the phone number for the VAD coordinator, the location of VAD placement, and the details of the specific device. The representative is available to give over-thephone suggestions, respond to a call if the location permits, or suggest transfer to the appropriate facility. CONCLUSION Mechanical circulatory support for patients with advanced heart failure has evolved considerably during the past 30 years and is now standard therapy at many medical centers.1 With more patients returning home after the implantation of these devices, emergency medicine clinicians must have a systematic and strategic way to approach these patients, and should be familiar with the basic principles of VADs and management strategies for this patient population. JAAPA REFERENCES 1. Slaughter MS, Pagani FD, Rogers JG, et al. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant. 2010;29 (4 suppl):S1-S39. 2. Suarez J, Patel CB, Felker GM, et al. Mechanisms of bleeding and approach to patients with axial-flow left ventricular assist devices.. Circ Heart Fail. 2011:779-784.
www.JAAPA.com
03/04/15 12:47 PM
Providing emergency care for patients with ventricular assist devices Valesia Henriques, MS, PA-C; Rahul Sharma, MD, MBA, FACEP
CASE A 23-year-old man presented to the ED complaining of brown, watery, nonbloody diarrhea and generalized fatigue for the past 2 days. He has a history of viral cardiomyopathy and received a left ventricular assist device (LVAD) about 1 year ago after an unspecified viral illness. He reports no problems with the LVAD since its implantation. He denies any recent travel or sick contacts, recent antibiotic use, melena, fevers, chills, chest pain, shortness of breath, palpitations, or abdominal discomfort. The remainder of his review of systems is negative. Physical examination The patient is a well-appearing black man in no acute distress. His vital signs are: BP via Doppler, 80 mm Hg sitting, 70 mm Hg standing, and 74 mm Hg lying down; heart rate, 76; temperature, 36.8° C (98.2° F); respirations, 20; and Spo2, 96% on room air. His skin is warm and dry; his pupils are equal, round, and reactive to light and accommodation; and his mucous Valesia Henriques practices in the ED at New York University’s Langone Medical Center in New York City. She completed a PA residency in emergency medicine at New York Presbyterian HospitalWeill Cornell Medical College in New York City. Rahul Sharma is executive vice chief of emergency medicine and an assistant professor at New York Presbyterian Hospital-Weill Cornell Medical College. The authors have disclosed no potential conflicts of interest, financial or otherwise. Acknowledgment: The authors would like to thank Lauren Krinsky, NP, VAD coordinator at NYU Langone Medical Center, for her help with this manuscript. DOI:10.1097/01.JAA.0000464278.21246.14 Copyright © 2015 American Academy of Physician Assistants
JAAPA Journal of the American Academy of Physician Assistants
0515 JAAPA_CR_OL_VADs_Puneet.indd 1
COURTESY OF THE NATIONAL INSTITUTES OF HEALTH
ABSTRACT Emergency medicine clinicians who care for patients with ventricular assist devices (VADs) must have basic knowledge of the device mechanics, population-specific patient assessment techniques, and specific hospital recommendations for care of these patients. This case report illustrates a systematic approach that can be used in the ED for evaluating patients with VADs. Keywords: ventricular assist device, emergency, patient assessment, nonpulsatile blood flow, dehydration, malfunction
FIGURE 1. Left ventricular assist device
membranes are dry. Neck examination shows no jugular venous distension. A “whirling” sound is heard with cardiovascular auscultation, and his lungs are clear to auscultation. His abdomen is soft and nontender with normal bowel sounds. He has no calf tenderness or lower extremity edema bilaterally. A neurologic examination is nonfocal. A clean driveline extends from the left upper quadrant of the abdominal wall to a controller located at the patient’s waistline. A green light illuminating on the controller indicates that the controller is receiving power. Two power cables extend outward on each side and connect to battery power or AC power. The lines are connected to a battery pack located on each side of the patient’s waist. (For more about VADs, see Figure 1). Laboratory and diagnostic testing An ECG shows a normal axis, normal intervals, and no ST-segment changes. A chest radiograph ordered to assess for percutaneous lead placement and fluid overload is interpreted as normal. Laboratory tests including electrolytes, complete blood cell count, coagulation factors, brain natriuretic peptide, lactate, and troponin are within normal limits. Management and treatment Upon ED arrival, the patient was placed on a cardiac monitor, vital signs were obtained, two peripheral IV devices were placed, and the VAD team was consulted. After further exploration of the patient’s presenting signs and symptoms, he was given IV fluids for dehydration. The patient remained under observation in www.JAAPA.com
03/04/15 12:47 PM
CASE REPORT
Key points Always start the clinical assessment with the ABCs. Common reasons for patients with VADs to present to the ED include device malfunction, infection, dehydration, myocardial infarction, thrombosis, and cerebrovascular event. Contact the facility VAD team or representative center as soon as possible to facilitate care planning. CPR may cause fatal hemorrhaging in patients with VADs and should only be used as the last lifesaving measure in these patients.
the ED for the next 4 hours and was ultimately diagnosed with dehydration secondary to diarrhea, cleared for discharge by the VAD team with care recommendations, and advised to follow up on an outpatient basis. DISCUSSION A VAD is a mechanical device that is surgically implanted into the patient’s chest and augments cardiac output. VADs can be a bridge to transplantation or destination therapy. Patients with VADs may be adequately treated and evaluated in the ED using a systematic approach that starts with the ABCs (airway, breathing, and circulation) and focuses on evaluating the entire patient, not just the implanted device. Providers should know not to use BP cuffs in patients with VADs, as a pulse often is undetectable. Order essential laboratory and diagnostic tests, including a complete blood cell count, basic metabolic panel, cardiac troponins, and B-type natriuretic peptide level; initiate resuscitation; and contact the appropriate facility VAD team or representative. In patients with VADs, arterial BP is most reliably assessed using a manual Doppler. Most VADs use continuous flow technology, resulting in a continuous, nonpulsatile blood flow. Because patients do not have a palpable pulse, taking BP with a manual cuff and stethoscope will not give accurate results. Instead, use a manual Doppler to obtain an accurate arterial BP, and pay special attention to the patient’s mental status and skin and lip color when assessing oxygenation level. During resuscitation, the goal is to maintain the mean arterial BP in the range of 70 to 80 mm Hg.1 This may be accomplished with vasoactive medications, inotropic medications, or intravascular fluid volume management.1 Respiratory rate and temperature may be obtained in the same manner for patients with or without VADs. However, pulse oximetry may be unobtainable and unreliable in patients with VADs because of diminished pulse pressure.1 A modified version of the primary survey can be used to establish a general clinical impression of the patient and the patient’s perfusion status. For patients responsive to verbal or painful stimuli, determine if the patient’s airway www.JAAPA.com
0515 JAAPA_CR_OL_VADs_Puneet.indd 2
is patent and intervene if necessary with supplemental oxygen, bag-valve-mask assistance, or endotracheal intubation. Use patients’ skin color and feel as an indicator of circulation. If the patient is unresponsive, immediately assess for a pulse and auscultate over the anterior chest for a “whirling” sound. Remember that some implanted fully functioning LVADs providing continuous flow do not provide the patient with a palpable pulse because of reduced pulse pressure. Initiating CPR in patients with VADs is controversial and site-specific; refer to the facility’s recommendations. In pulseless patients with VADs, providers should use every adjunctive resuscitation modality, including fluids, antiarrhythmics, vasoactive agents, and/or inotropic medications before initiating CPR. If the “whirling” sound of the motor can be heard during auscultation, CPR should not be initiated because the force of adequate compressions may irreversibly damage the device or cause fatal hemorrhage. CPR in a patient with a VAD is indicated if the patient is pulseless, unresponsive, and the device is not functioning (no “whirling” sound during auscultation). Due to the risks, CPR should be a last resort for resuscitation. Common reasons for patients with VADs to present to the ED include infection, device alerts or malfunction, bleeding, cerebrovascular events, dehydration, trauma, thrombosis, myocardial infarction, dysrhythmias, and right heart failure. A high index of clinical suspicion in these patients will prevent missed cases of potentially fatal clinical diagnoses.
Patients with VADs can become dehydrated because they tend to limit their oral intake and are on a salt-restricted diet. Infection Erythema or drainage from the driveline site should immediately prompt an investigation for causes to rule out sepsis. If the patient’s vital signs are unstable or if the patient is tachycardic, hypotensive, or febrile with or without a known source of infection, treat the patient for sepsis. Focus on maintaining volume status without causing volume overload. Device alerts or malfunction Alerts that may prompt patients to present to the ED include loss of power to the pump, for example, from disconnecting both power leads simultaneously or disconnecting the percutaneous lead from the controller.1 Bleeding Most if not all patients with VADs are on anticoagulants to keep their international normalized ratio between 2 and 3. Across studies, the most commonly Volume 28 • Number 5 • May 2015
03/04/15 12:47 PM
Providing emergency care for patients with ventricular assist devices
reported sources of bleeding are epistaxis, GI tract bleeding, bleeding within the mediastinum and thorax, and intracranial hemorrhage.2 In patients with VADs who present with unstable vital signs, altered mental status, or complaints of dark stools, rule out a hemorrhagic process. Cerebrovascular events If the patient presents with symptoms that are concerning for a stroke, consult neurology and obtain a head CT to rule out intracranial hemorrhage or infarct. Dehydration Cardiac devices need volume to function properly. Patients with VADs can become dehydrated because they tend to limit their oral intake and are on a salt-restricted diet.1 However, as part of the differential diagnosis, also consider conditions that reduce the return of blood to the left ventricle, such as right ventricular failure, cardiac tamponade, and pulmonary hypertension.1 Once the possibility of device malfunction, myocardial infarction, infection, and neurologic compromise has been excluded, a diagnosis of dehydration can be entertained and the patient can be given adequate fluid resuscitation. Contact the VAD team as soon as possible. The initial contact person typically is a nurse practitioner or physician assistant (the rest of the team consists of cardiac surgeons, cardiologists, case managers, social workers, and other
JAAPA Journal of the American Academy of Physician Assistants
0515 JAAPA_CR_OL_VADs_Puneet.indd 3
support staff). Most patients will have a detailed medicalalert bracelet or a tag on the controller around their waist that lists the phone number for the VAD coordinator, the location of VAD placement, and the details of the specific device. The representative is available to give over-thephone suggestions, respond to a call if the location permits, or suggest transfer to the appropriate facility. CONCLUSION Mechanical circulatory support for patients with advanced heart failure has evolved considerably during the past 30 years and is now standard therapy at many medical centers.1 With more patients returning home after the implantation of these devices, emergency medicine clinicians must have a systematic and strategic way to approach these patients, and should be familiar with the basic principles of VADs and management strategies for this patient population. JAAPA REFERENCES 1. Slaughter MS, Pagani FD, Rogers JG, et al. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant. 2010;29 (4 suppl):S1-S39. 2. Suarez J, Patel CB, Felker GM, et al. Mechanisms of bleeding and approach to patients with axial-flow left ventricular assist devices.. Circ Heart Fail. 2011:779-784.
www.JAAPA.com
03/04/15 12:47 PM
