Eric M. Rudnick, MD, FACEP Medical Director Northern California EMS

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1 Technology Complex Patient Eric M. Rudnick, MD, FACEP Medical Director Northern California EMS 2012 Northstate Prehospital Conference 1

2 Old School Technology Bolts, Trephining, and the Stethoscope 2012 Northstate Prehospital Conference 2

3 New School Technology Microprocessors and Nano-machines 2012 Northstate Prehospital Conference 3

4 Regarding Patient Devices Always listen to the local expert in the care of these complex patients. Many times the patient and/or the family Northstate Prehospital Conference 4

5 Sir William Osler 2012 Northstate Prehospital Conference 5

6 History and Physical Examination Sir William Osler July 12, to December 29,1919 Father of Modern Medicine Out of the lecture hall to the bedside Bedside manner, empowering patients, and autonomy in clinical practice Renowned practical joker Eagerton Y Davis Listen to your patient, he is telling you the diagnosis 2012 Northstate Prehospital Conference 6

7 What is a Ventricular Assist Device (VAD)? Help failing hearts pump blood. Advanced or end stage heart failure patients. Heart failure effects 5 million Americans and each year an additional 550,00 are diagnosed. Heart muscle is too weak to adequately pump blood Northstate Prehospital Conference 7

8 Bridge versus Destination Therapy Prolonged wait and limited donors 3,000 donor organs each year world-wide "buy time" for the patient or eliminate the need for a heart transplant Longer-term or destination therapy in endstage heart failure patients when heart transplantation is not an option Northstate Prehospital Conference 8

9 REMATCH Study 48% decrease in the death rate from all causes with the LVAD over the first 2 years of use. One-year survival in the LVAD group was 52% compared with 25% in the group receiving optimal medical Northstate Prehospital Conference 9

10 REMATCH Study 8% (1 out of 12) survived two years in the optimal medical management group. 23% were alive at 2 years in the LVAD group. 1-year survival for patients under 60 years was 74%. Quality of life improved in the LVAD group. Conducted on only the sickest patients, who had no alternative options Northstate Prehospital Conference 10

11 LVAD or Pump Basics The LVAD (pump) has an inflow conduit that takes blood from the weakened ventricle and pumps it into the aorta via an outflow tract. The pump p is placed in the upper part of the abdomen. The driveline is another line (tube) that leaves the body (percutaneously) through the abdominal wall. This is connected to the device s battery and control system Northstate Prehospital Conference 11

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13 First Generation Device Pulsatile Blood flow 2012 Northstate Prehospital Conference 13

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16 Second Generation Device Non- Pulsatile Blood Flow Blood enters from the left ventricle Rotor spins at fixed speed Blood exits/returned to the aorta 2012 Northstate Prehospital Conference 16

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19 Sl h l Slaughter et al N Engl J Med 2009;361: Northstate Prehospital Conference 19

20 Percutaneous Driveline 2012 Northstate Prehospital Conference 20

21 Blood Pressure 1 st Generation Pulsatile Traditional BP Pulse Oximetry reflects oxygen saturation Palpated pulse may appear irregular LVAD pulse and native heart pulse not synchronized LVAD rate reflects perfusion (displayed on controller unit) Palpated pulse (LVAD +/- native heart) will be different from EKG heart rate (native heart only) 2012 Northstate Prehospital Conference 21

22 Blood Pressure 2 nd Generation Non-pulsatile axial turbine The pump is continuous flow the impellar may rotate at a rate of between 5,000 and 10,000 rpm No audible pump cycling Cuff BP will not be measurable Low from poor native heart cardiac output Pulse oximetry will not see a capillary pulse wave and may not display a value Unless native heart has sufficient cardiac output) EKG shows native heart rate and rhythm 2012 Northstate Prehospital Conference 22

23 Blood Pressure / Basics 2 nd Generation LVAD cardiac output displayed on controller unit Alarms at less than 2 liters/min output Doppler to obtain a Mean BP Goal Mean BP is Northstate Prehospital Conference 23

24 Blood Pressure Basics 2 nd Generation Low BP Just because you can t get a BP doesn t mean it is low Is the patient perfusing? If yes, probably okay Cap refill Mentating ti properly If BP low needs fluid VAD patient is preload dependent needs full tank 2012 Northstate Prehospital Conference 24

25 Special Considerations Non-Pulsatile flow LVAD patients will be on both ASA and Coumadin Bleeding risk especially in trauma Pulsatile flow LVAD patients will be on ASA 2012 Northstate Prehospital Conference 25

26 Common Complications Arrhythmia atrial and ventricular (more common) Bleeding GI Bleeding Hemorrhagic CVA Stroke Ischemic Infection Carefully inspect drive line site Never tug or pull at it 2012 Northstate Prehospital Conference 26

27 Arrhythmia Heart failure patients are at increased risk for arrhythmias Many VAD patients will have an implanted cardioverter-defibrillator (ICD) or pacer-icd Atrial dysrhythmias will not affect LVAD Synchronized cardioversion and defibrillation OK using usual pad placement Move controller unit away from defibrillation pads Patient may still be conscious and perfusing 2012 Northstate Prehospital Conference 27

28 Arrhythmia Patients having arrhythmia problems may be functioning fairly normally Despite being in a lethal rhythm (VT), blood is still flowing to the body. They may have minimal symptoms, not be alert, or unconscious 2012 Northstate Prehospital Conference 28

29 Bleeding Most common in the GI tract and the brain Risk of bleeding is increased because LVAD patients need to be on anticoagulation Warfarin and ASA (2 nd Generation devices) GI bleeding is often from Arterial-venous malformation (AVM) Ulcer Bleeding in the brain is often from AVM Hypertension (HTN) Stroke ischemic (pump?) or hemorrhagic Trauma 2012 Northstate Prehospital Conference 29

30 Infection Driveline Usually due to trauma Excessive moisture Pump Pocket Extensive driveline infection Systemic Can be from an extensive driveline infection From another source May quickly develop septic shock 2012 Northstate Prehospital Conference 30

31 Acute MI Considerations May not have hemodynamic compromise with LVAD maintaining perfusion Right Ventricular MI can decrease filling of the LVAD and cause pulmonary edema and/or hypotension Ventricular paced rhythms should not be read as ***Acute MI*** by 12 lead ECG algorithm 2012 Northstate Prehospital Conference 31

32 Special Pump (LVAD) Considerations Red Heart Alarm : mechanical pump failure Symptoms: dyspnea, nausea, syncope, loss of consciousness LVAD pump filling depends upon right heart filling Hypervolemia, right heart failure (e.g. RV infarct) or cardiac tamponade reduces right heart cardiac output Treatment: IV saline bolus at least 500 mls 2012 Northstate Prehospital Conference 32

33 Warning! Warning! Code Situation Hazard Alarm: Red Heart Tone: You will hear a CONTINUOUS alarm. Pump has stopped Low flow <2.5 liters/minute Di Driveline is disconnected td 2012 Northstate Prehospital Conference 33

34 Code Situation Follow ACLS protocol for Intubation Medication administration Defibrillation Most patients t will have an AICD External Pacing and defibrillating is okay Don t place paddles over AICD or driveline of LVAD 2012 Northstate Prehospital Conference 34

35 CPR if Clinically Indicated What does this mean? Needs to be viewed cautiously because CPR may result in dislocation or damage of the cannulas or ventricle rupture, requiring emergency thoracotomy and heart surgery. But, if the patient is dead then can we really hurt them? 2012 Northstate Prehospital Conference 35

36 CPR or No CPR, That is the Question Unconscious Apneic Unresponsive Pump is not running (Red Heart Alarm) CPR is indicated If there is good perfusion and pump is still running, CPR is not indicated Find the other reason for unresponsiveness CPR as an absolute last resort 2012 Northstate Prehospital Conference 36

37 Reverse 911 Call for EMS These patients are leading normal lives Traveling, golfing, and riding motorcycles For example: Patient shopping at mall Battery alarm goes off and forgot spares Called 911 Code 3 transport t to patient s t home with lights and siren Local hospital would not have proper equipment 2012 Northstate Prehospital Conference 37

38 Transport to Hospital Bring all the equipment to the hospital! Back-up system controller and batteries Contact receiving hospital you are en route with a patient who has a LVAD Brownie points: contact t the implanting hospital LVAD coordinator should have already been contacted even before 911 initiated 2012 Northstate Prehospital Conference 38

39 Treatment Summary BLS and ALS treatment guidelines and procedures are applicable in LVAD patients. All ALS drugs are applicable in LVAD patients. There are No absolute contraindications ti for treatment t t guidelines or drugs. CPR: Unconscious, unresponsive, apneic, and with Red Heart Alarm audibly sounding on the controller unit Northstate Prehospital Conference 39

40 Treatment Summary Take all LVAD equipment to hospital Power Base Unit All batteries Hand pump (displacement/pulsatile LVAD unit only) Keep patient s trained companion with the patient (will manage LVAD) Anticipate expeditious (damn fast) interfacility transfer to LVAD program home hospital 2012 Northstate Prehospital Conference 40

41 Automatic Internal Cardioverter Defibrillator (AICD) Developed 1980 s Implantable now inserted transvenous Treat cardiac tachydysrhythmias especially ventricular Sudden death survivors due to VF or VT (secondary prophylaxis) Primary prophylaxis based upon guidelines Sensors can hopefully recognize supraventricular tachycardias minimize shocks Magnet temporarily turns off defibrillator but not pacing 2012 Northstate Prehospital Conference 41

42 Automatic Internal Cardioverter Defibrillator Fixed rate (asynchronous) R on T risk Demand (synchronous) Magnet inhibition temporarily reprograms into asynchronous mode. If left on for 30 seconds, ICD turned off. To reactivate, remove the magnet and then replace the magnet. Listen for the tone(s) 2012 Northstate Prehospital Conference 42

43 Automatic Internal Cardioverter Defibrillator (AICD) Complications Pain Bleeding Pneumothorax and/or hemothorax Cardiac perforation Infection Lead dislodgment Lead fracture Inappropriate shocks Erosion device through skin Resuscitation defibrillation 10 cm away 2012 Northstate Prehospital Conference 43

44 External Defibrillator What to do? Temporary device 2012 Northstate Prehospital Conference 44

45 Pacemaker 2012 Northstate Prehospital Conference 45

46 Pacemaker Indications Sick sinus Symptomatic bradycardias Tachycardia-bradycardia syndrome Complete atrioventricular block (3 rd degree) Prolonged QT Generator and pacing leads, inserted transvenous Pulse generator placed subcutaneously or submuscularly 2012 Northstate Prehospital Conference 46

47 Pacemaker Complications Failure to output Failure to capture Failure so sense Pacemaker-mediated d tachycardia Runaway pacemaker Pacemaker syndrome 2012 Northstate Prehospital Conference 47

48 Pacemaker Complications Twiddler s syndrome Pain Bleeding Pneumothorax and/or hemothorax Cardiac perforation Infection Lead dislodgment Lead fracture Erosion device through skin 2012 Northstate Prehospital Conference 48

49 Home Infusions Insulin Pulmonary hypertension Antibiotic and other anti-infectives Vasopressors and inotropes - i.e. Dopamine for heart failure Hemophilia (factor therapy) Parenteral nutrition Intravenous gamma globulin (IVIG) Colony stimulating factors Chemotherapy Pain management 2012 Northstate Prehospital Conference 49

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53 Intratheal Pumps and Infusions Medications Baclofen Morphine Indications Pain from severe spinal arthritis, spinal stenosis Cerebral Palsy Access port to refill medications Programmable Battery changing is surgical procedure 2012 Northstate Prehospital Conference 53

54 Intratheal Pumps and Infusions Complications Pain Bleeding Infection Erosion 2012 Northstate Prehospital Conference 54

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56 Ventricular Peritoneal (VP) Shunt Placed for hydrocephalus Decrease intracranial pressure Drainage of CSF into abdomen Complications and issues Disconnection Fracture or dislocation Erosion of shunt into other organs Infection at the site and/or deep needs emergent removal 2012 Northstate Prehospital Conference 56

57 Ventricular Peritoneal (VP) Shunt Signs and Symptoms caused by malfunction Headache Seizures new or increased activity Lethargy Vomiting with little to no nausea Altered personality Altered intellectual ability Visual disturbance 2012 Northstate Prehospital Conference 57

58 Ventricular Peritoneal (VP) Shunt Young child Impatient Grouchy Whiny Anxious Bulging fontanel and/or head enlargement Mental and/or physical abilities (milestones) lost Downward deviation eyes diesel therapy 2012 Northstate Prehospital Conference 58

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61 Deep Brain Stimulator 2012 Northstate Prehospital Conference 61

62 Deep Brain Stimulator Indications Parkinson s Disease Depression Parkinson s Disease inserted into Thalamus or subthalamic region Eradication tremor and dystonia Programming issues 2012 Northstate Prehospital Conference 62

63 Deep Brain Stimulator Complications Side effects of stimulation Numbness Weakness Double vision Imbalance Problems thinking Superficial bleeding Bleeding into the brain (stroke) and/or death Wound infection Fracture of hardware Erosion 2012 Northstate Prehospital Conference 63

64 Vagus Nerve Stimulator 2012 Northstate Prehospital Conference 64

65 Home Dialysis Hemodialysis Peritoneal 2012 Northstate Prehospital Conference 65

66 Dialysis Cardiovascular mortality is times higher in dialysis patients than the normal population. All cause mortality in dialysis patients older than 65 years is more than 6 times the general population Northstate Prehospital Conference 66

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70 Dialysis At Arterial-Venous ilv (AV) Shunt malfunction Bleeding can be severe * Don t use tourniquet Infection Clotting Electrolyte abnormalities Hyperkalemia sodium bicarbonate and Albuterol Arrhythmias Monitor abnormalities Acidosis Hyponatremia Mental Status changes Seizures Fluid overload 2012 Northstate Prehospital Conference 70

71 Dialysis Hypocalcemia or Hypermagnesemia Weakness Arrhythmias Hypocalcemia Tetany Parasthesia Hypermagnesemia Neuromuscular depression Loss of reflexes 2012 Northstate Prehospital Conference 71

72 Dialysis Sepsis cautious fluid administration Cardiac arrest standard ACLS with consideration of sodium bicarbonate (base hospital) Pericardial tamponade Fluid overload - nitrates 2012 Northstate Prehospital Conference 72

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74 Dialysis Peritoneal Dialysis Peritonitis occurring once per year Abdominal pain generalized versus localized Fever Cloudy effluent ask the patient Site infection local site redness 2012 Northstate Prehospital Conference 74

75 Halo Devices 2012 Northstate Prehospital Conference 75

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77 External Fixators 2012 Northstate Prehospital Conference 77

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80 Exoskeletons 2012 Northstate Prehospital Conference 80

81 Robotic Limbs 2012 Northstate Prehospital Conference 81

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83 What Does The Future Hold? 2012 Northstate Prehospital Conference 83

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1 out of every 5,555 of drivers dies in car accidents 1 out of every 7692 pregnant women die from complications 1 out of every 116,666 skydives ended

1 out of every 5,555 of drivers dies in car accidents 1 out of every 7692 pregnant women die from complications 1 out of every 116,666 skydives ended in a fatality in 2000 1 out of every 126,626 marathon