71 year old male with “seizures” that prove to be ICD shocks

EMS is called to the residence of a 71 year old male for “seizures.”

On arrival the patient’s spouse meets the ambulance outside and hurries the paramedics along saying “Come quickly! Please help him!”

The paramedics arrive at the patient’s side just in time to see him receive an ICD shock.

They ask how long this had been going on.

“That was my 15th shock!”

The patient states that he “felt himself going faint” just prior to the first shock.

The cardiac monitor is attached and the following rhythm strips are recorded.

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The patient appears anxious. His skin is pink, warm, and moist.

Numerous skin tears are noted to the patient’s arms which the spouse states are related to convulsions induced by the ICD shocks.

Vital signs are assessed.

  • RR: 20
  • HR: 60
  • NIBP: 108/72
  • SpO2: 98% on room air

Past medical history:

The EMS crew learns that this patient survived two sudden cardiac arrests prior to receiving his first ICD in 1992. The device was replaced in 2008. The patient does not have his device ID card but knows that it was made by St. Jude Medical.

Medications:

The patient states he takes several medications but he can only remember one of them: Coumadin.

The EMS crew contacts Online Medical Control and receives permission to apply a ring magnet to the device. The magnet is applied and taped in place. The tape doesn’t hold and a FF is assigned to hold the magnet over the device.

A 12-lead ECG is obtained.

2010_08_21_1854_wm

And another.

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A bigeminal rhythm is noted on the monitor.

2010_08_21_1859_wm

The patient is loaded for transport.

IV access is achieved.

En route the the hospital serial 12-lead ECGs are obtained.

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Vital signs are re-assessed.

  • RR: 18
  • HR: 76
  • NIBP: 102/70
  • SpO2: 99% on room air

The patient feels much calmer and says, “Please don’t let that thing shock me again.”

A final 12-lead ECG is captured on arrival at the hospital.

2010_08_21_1915_wm

What do you think the patient would say was the most important thing the EMS crew did for him?

For a full discussion of inappropriate or ineffective ICD shocks, including when and how to apply a ring magnet, see the following links.

Inappropriate or ineffective ICD shocks: Part 1

Inappropriate or ineffective ICD shocks: Part 2

Inappropriate or ineffective ICD shocks: Part 3

Updated 01/06/2016

61 Comments

  • “do you have a DNR?” =P

  • Anonymous says:

    Actually, the patient had to survive not one but two sudden cardiac arrests to qualify for his first ICD back in 1992! So I’m pretty sure he doesn’t want to die now. 😀

  • that’s funny – i just saw on FB that someone else mentioned DNR. i’m totally trying to be funny (probably in vain) but i wonder if she was serious about it.

  • Anonymous says:

    I sensed that she was! :)

  • Adam Thompson, EMT-P says:

    I would

    1. Immediately place my combo-pads on the patient, just in case his batteries took a dump.
    2. Burn a longer strip, just to make sure we aren’t dealing with TdP
    3. Obtain SAMPLE Hx.
    4. Ask the patient if he has the magnet for the device (in case it’s needed in the future)
    5. Administer O2 & Versed
    6. Consider dysrhythmics
    7. Transport to a PCI/Cardiac facility.

    This is is all considering that the patient was relatively still during these ECG captures.

  • Anonymous says:

    Adam –

    Just out of curiosity, what might you do different if dealing with TdP? Let’s say for the sake of argument that the EMS crew has its own ring magnet. Would you apply it? Why or why not?

    Tom

  • Amremtman says:

    Magnet just in case and mag sulfate?

  • Geoff says:

    I would try to get a longer strip as well. We do not administer anti-dysrhythmics to a wide complex rhythm, so my only options would be O2 & transport. I suppose we could possibly cardiovert/defib if we see more VTach or VFib, but I’m assuming the AICD would take care of that before we could.

    We’ve never received any specific training regarding the magnet, so even if available I would not use it without a doctor’s okay…looking forward to more on this though.

  • Anonymous says:

    Amremtman –

    I personally agree with magnet application for this case. In fact, that’s exactly what the EMS crew did. I’ll be posting the rest of the case tomorrow. Interesting idea about the mag sulfate! I agree that the rhythm looks polymorphic and cyclical. I think you’ll be in a better position to make treatment decisions after you see some 12-lead ECGs.

    Tom

  • Anonymous says:

    Geoff –

    Here’s my question. If the patient is tolerating the VT, do you really want the ICD to shock it again and again? To put it another way, are ineffective ICD shocks benign events?

    Tom

  • Russ says:

    Looks like this pt needs an amiodarone drip…..Works like a charm.

  • Todd Cage says:

    I’d like to see a long strip and a 12 lead as well. I’d also like to know what meds he is on, which may help understand the cause of the polymorphic appearance of his rhythm. The last patient I cared for with ineffective ICD shocks was in VT. We gave a lidocaine bolus based on his history of receiving lidocaine for his VT. It accelerated the rhythm which prompted an additional ICD shock, which terminated the arrhythmia and restored normal sinus rhythm.

  • Anonymous says:

    Russ –

    All antiarhythmics carry certain risks. I don’t share your confidence in amiodarone and I can’t say that I’ve ever seen it “work like a charm”. However, it would seem that in this case the potential benefit is worth the risk, provided that the runs of polymorphic VT are not secondary to a prolonged QT-interval. I’d still consider the Hs and Ts first.

    Tom

  • rocky says:

    Im assuming, magnet therapy is to turn the pacemaker off? can anyone other than a doctor do that? would like to feel an actual pulse and vitals to see if what is on the monitor is actually what is happening to my pt. i mean after 15 shocks i would bet the pt. is in a lot of pain, therefor causing a lot of interference w/ monitor. definitely a longer strip would be helpful. Im going to call this wide complex v. tach but not Tdp ( maybe a run) but to short of a strip for me to call it. okay treatment.
    1. primary assesment
    2. O2
    3. IV
    4. shocker pads
    5. i would transmit to ER and talk to doctor about sedation if vitals are good (this guy is in a lot of pain im guessing)
    6 or still talk to doctor and consider cardizem drip
    3.

  • Anonymous says:

    Todd –

    At least lidocaine (unlike amiodarone) shortens the QT-interval, which makes it a better choice for Torsades. When treating arrhythmias with antiarrhythmics I always think of the “post hoc ergo propter hoc” fallacy. If you do a rain dance and it rains did the rain dance make it rain? At least with adenosine it’s obvious when the drug terminates the arrhythmia!

    Tom

  • Anonymous says:

    Rocky –

    The ring magnet is just to disable the tachy (shocking) functions of the device. The brady (pacing) functions of the device would be unaffected. My EMS system carries a ring magnet specifically for this purpose. Sedation is not a bad idea at all! I would definitely lay off of the diltiazem. I would never give a calcium channel blocker to a wide complex tachycardia unless I knew with 100% certainty it was not VT.

    Tom

  • Geoff says:

    Good point. Your explanation later on about the magnet turning off that’e shocking feature w/o affecting the bradycardic feature answered a big question I had. So, if we use the magnet we can get a better picture of what’s going on to treat appropriately. What I need to figure out is, are most people with AICDs issued a magnet? Are these device specific?

  • Anonymous says:

    The magnets themselves are not device-specific, but there are some differences in how the various manufacturer’s devices will respond to ring magnet application. The best thing to do is to ask to see the patient’s device ID card. I do have a summary of how the devices respond to magnet application in “Inappropriate or ineffective ICD shocks – Part III”. The link can be found in the “Featured Posts” tab at the top of my blog.

  • Jeff Birrer says:

    Pretty straight forward Torsades= 2grams of Mag. Put o. The defi. Pads and consider shutting off the ICD with the magnet. I would let it keep doing it’s job, unless the patien showed signee of significant distress then I would take over and run it as an impending code… At that time I would consider early intu ation to avoid the crash airway.

  • Ben Jordan, EMT-P Student says:

    1. O2 15L x NRB
    2.Combi-Pads on Pt
    3. Large bore I.V. Run TKO for now
    4. 12-Lead
    5. Confirm rhythm. Mag sulfate for TdP or Lidocaine for VT.
    6. Diesel bolus! Rapid transport to ED.

    My service doesn’t have AICD magnets or a protocol for them. As others have stated, it would help a lot to see more of the rhythm. Explore Hs and Ts to find out what is causing the rhythm. Transmit 12-leads to ED to see if they have any further advice.

  • ChaseB. says:

    Oh wow, nice scenario. I was contemplating it right as you were updating.

  • Anonymous says:

    Jeff –

    I don’t have a problem with the 2 grams of MgSO4 but what if that doesn’t work? Also, for the sake of discussion, what is the difference between Torsades and polymorphic VT? Remember, you can turn off tachy therapy with a magnet but you can always turn it back on!

    Tom

  • Anonymous says:

    Ben –

    Sounds reasonable to me!

    Tom

  • Anonymous says:

    Thanks, ChaseB.! I need to learn to reply directly to the comment I’m responding to instead of leaving a new comment at the top! Still getting used to my new blog. :)

    Tom

  • Docsnavely says:

    We don’t have magnets where I work, so i would go with an amiodarone drip. If you sedate this person with a benzo, you run the risk of dropping the pressure below your antidysrhythmic threshold. If you can control the underlying morphology, you can get the ICD to possibly play nice.

    Another thing to consider after looking at the strips shortly before arrival at the hospital is that the rhythm seems to be under a bit more control with just pacing. I wouldn’t be able to r/o an ICD malfunction. I’ve had a patient with a malfunctioning ICD before and ran on him multiple times a month because his cardiologist wouldn’t change out the old one for a new one due to the risk/benefit of replacement. The nasty initial rhythm might be attributed to the myocardium being irritated beyond belief from the repeated electricity.

    People are going to mag in their comments and it seems to be a bit premature in my opinion. The rhythms shown initially could be torsades, but there is no way to truly tell IMO because of the artifact and irregular pacer spikes. I would be more concerned with the consequences of making this patient hypermagnesic than I would be with giving a traditional antidysrhythmic like amio or lido.

    Just my $.02

    These head scratchers are fun (unless it’s you in the back). Good case!

  • Anonymous says:

    Docsnavely –

    I’m no expert on MgSO4 but at least one of our ED docs believes that 2 grams can’t hurt anyone and will often help whether the rhythm is TdP or not. I agree with you that benzos should be used sparingly due to the borderline pressure (I think turning off the tachy functions of the device is a better strategy) but don’t forget that amiodarone will also lower the patient’s blood pressure! I personally would not give it with a pressure of 102/70 if the rhythm seemed to be doing “better” as in this case. Another good point that the ICD shocks could be irritating the myocardium and creating some of the irregularity!

    Tom

  • Docsnavely says:

    Tom, you’re right about the mag. I used to be the mag king at the last agency I worked for because they had no problems with it’s use (regardless of the ER docs’ gripes). Where I work now they’re more scared of the mag. It all depends on who you work for I guess.

    I agree with you on the amiodarone and at that point it falls under judgement, what you’re comfortable with and what your gut feeling is. I would still use it because if I can narrow those complexes out, I can slow down the amio and titrate prn where if I use a benzo like versed, the patient will become a bit more comfortable but you’re not doing anything to actually treat the condition. You’re gambling…. will the amiodarone work, correct the rhythm and in turn the pressure, or will it just exert it’s full 3 way blocking potential and dump the patient’s b/p?

    fun fun fun! :o) it’s hard sometimes to get into a good story like this with your work colleagues…. usually they just want to go to sleep or talk on their cell phones, or flat out tell you they don’t know and would just haul ass to the hospital.

  • Docsnavely says:

    I would think that the patient as they presented would be a sign of significant distress. Why not try and work a solution instead of thinking of it as an impending code? The guy still had a b/p.

  • Anonymous says:

    Very true!

  • NGAMEDIC says:

    Tom, I am with you on the amio. I suppose it works ok in the clinical/ hospital setting, but coming from the “old school” method of thinking, and actually seeing positive effects, I still lean towards Lidocaine as my first drug of choice for VT/VF. I think assess, HF O2, two 18 or better Bilateral lines of NS with 200ml bolus for pressure, and then at KVO for maintenance, prepare your monitor for potential cardiovert/defib, 12 lead with transmit and maybe 1mg/kg of lidocaine to see the effect. Code III transport to a cardiac facility.
    You definately better be in contact with med control on this one, because
    1.) they need to know what you have stepped in, and what is heading their way.
    2.) giving the doctors the choice to make the critical decision of drug choice from the transmitted strips will take the monkey as well as the liability off your back,

  • bikemedic says:

    I think the magnet was a smart move. I would be wary of Amiodarone due to the long-term effects and the fact that he couldn’t recall his meds. What if he is already on Amio? I think it’s best to let the hospital, who may have a better history on file, to perform the necessary tests and decide which antidysrythmic is best for the pt. If an EMS crew can relieve his pain through a minimally invasive method and maintain adequate vitals until he receives comprehensive care then we’ve done what’s best for the pt. As for mag, I’ve never been a believer in giving meds for meds sake. If the pt is maintaining adequate vitals and perfusion then there is no reason to give a med just because “it won’t hurt”. Especially one without a dependable history. IV, O2, and monitor is sometimes the best treatment for our pt’s.

  • Anonymous says:

    bikemedic –

    I agree with your philosophy, have shouted it from the roof top many times, and I don’t give meds for meds sake either. I would consider MgSO4 for this case not just because “it won’t hurt” but because also because “it might help” especially if the polymorphic VT turns out to be TdP. Risk/benefit (low risk/possible benefit) as opposed to amiodarone (moderate risk/possible benefit). If you’re worried about the patient getting too much magnesium you could check deep tendon reflexes first.

    Tom

  • Keefertrace says:

    Tom, love the Latin reference. That on should be hammered in to all medics in school scenarios! Keep up the excellent discussion strips. Even those I know who swear they have sen it all, done it all get in to good debates over your blogs!!

  • Terry says:

    I think the pt needs a refund on his ICD/pacemaker. Lets look at this from the first strip. This clearly looks like a lethal disrhythmia that needs to be shocked which is what the pts ICD is doing. If you look at the other strips it is apparent that his pacemaker is not performing as is should. It is very slow and there is no capture. The pts heart is very irritated hence the trosades or v-fib either way the pt needs an electrical stimulus. By putting a magnet to his ICD you take away a 1 to 2 joule shock and now must give him 150 joules depending on your monitor. We quit carrying magnets on our department. You must fix the disrhythmia with either an antidysrhythmic drug which has been talked about or fix the pacemaker. Did the crew externally pace him? If they didn’t it is interesting how by placing the magnet on the ICD his pacemaker eventually started to do what it is suppose to do. The last strip is a happy heart with no more lethal disrhythmia. Kudos to the crew.

  • Anonymous says:

    Terry –

    Look again! The pacemaker has a lower rate limit of approximately 75 and seems to be capturing okay (although it’s easier to see in the 12-lead ECGs than the first couple of rhythm strips).

    The problem I have with your theory regarding the ICD is that it presupposes that the ICD leads are properly placed and shocking correctly and it forgets that the magnet can be removed if the patient goes into a lethal arrhythmia and loses consciousness (which should resume tachy therapy).

    In a situation like this I think of Einstein’s definition of insanity! If shocks number 13, 14, and 15 didn’t correct the problem, why put money on shocks number 16, 17, or 18? Not to mention that ineffective ICD shocks can worsen ventricular arrhythmias!

    All the crew did was temporarily disable tachy functions with the ring magnet and provide supportive care, including calm reassurance. I’m actually surprised that your system removed the ring magnets. Did you have a sentinel event?

    Tom

  • Anonymous says:

    Thanks for the feedback, Keefertrace!

  • Medic1408 says:

    We also do not have magnets. What I would like to know is, are the wide complex beats perfusng or not? If so, you dont want to knock them out without having atropine or a pacer ready to go due to the underlying rhythm rate. If they are not perfusing then what is the underlying rate? Low rate? Increase it and they ectopy may go away. If it is Torsads, Mag would be appropriate along with Amiodorone. High flow O2 alone has been known to decrease the arrhythmia or knock it out totally due to hypoxia. I guess I really need a little more info to make a good educated guess on this one.. Great Job posting cases like this!

  • Anonymous says:

    Medic1408 –

    I think part of the justification for ring magnet application is to allow the underlying rhythm (including the pacemaker) to emerge and “see what we’ve got”. I would suggest that if the patient is conscious then the beats are perfusing at least enough to maintain consciousness. You are correct in that overdrive external pacing may be therapeutic for TdP (although it’s a poorly performed skill by all levels of health care providers) and I agree with you regarding the MgSO4. The amiodarone? If the underlying QTc is prolonged (which is what distinguishes TdP from polymorphic VT) then I’m not sure I’d give an antiarrhythmic that prolongs the QT-interval! Having said that, the 2005 AHA ECC guidelines hedge on this point a little bit. I’m glad you enjoyed the case! These are fun ones to post.

    Tom

  • Medic1408 says:

    True, but us without magnets do not have that luxury . I also agree with the use of Amiodorone but in this particular case I think I would contact med control to get a second opinion. I would have second thoughts about using it if it were me on the call but I was just acknowledging that it may be indicted as one of the other medics brought up. I wasnt really clear on that point. Thanks.

  • Anonymous says:

    That’s not a bad idea, Medic1408! Sometimes a second opinion is a good thing! :)

    Tom

  • Medic1408 says:

    Just curious since I dont have experience with the magnets. If a patient went into pulseless v-tach or v-fib would you remove the magnet and allow the ICD to do its job or would you externally defib or both?

  • Anonymous says:

    I would re-enable tachy therapy (for Medtronic and St. Jude Medical devices this is a simple matter of removing the magnet) and see if the ICD shocked the VT/VF. If it failed to shock or the rhythm didn’t convert I would put the magnet back in place and manually defibrillate.

    Tom

  • Geoff says:

    Thanks,

    I remember reading something about them before on your site, I’ll go back and review. Great case.

  • I think I’d use the mag.

  • Adam Thompson, EMT-P says:

    Tom,

    I think you have covered it, but applying the ring magnet could make it easier to discover TdP, and since the electrical therapy isn’t working, I would initiate a Mag drip.

  • Jdpmemt says:

    Tom,

    What about placing the magnet to stop tachy function. Looks like I would have gone with polymorph vt. Given Lido bolus. Std a lido drip. Called on consult for mag? Place pacer patches incase magnet or pacer stopped working. Held off amio due to bp. If he has history of seizures may take a benzo already. More worried about amio with BP. If he is in pain fent would work. Also let’s not forget about basics. Feel his pulse. Look at his skin etc…. Thoughts?

  • Terry says:

    Tom-
    That is true the shocks are not being effective after hitting him up to 15 times. I didn’t even think about the leads being improperly placed— all the more reason for a refund. (-: The first couple of strips show an occassional pacer spike which lead me to think that the pacer wasn’t working correctly. This case is a good example of why we should put the magnets back on the rigs. What do you mean by a sentinel event?

    Terry

  • Anonymous says:

    You’re a clever man Russell!

    Tom

  • Anonymous says:

    I think I agree with everything you just said!

    Tom

  • Anonymous says:

    From the Joint Commission website: “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.”

  • Amy K. says:

    shouldn’t the magnet placed turn off the pacer as well as the AICD? most magnets that are on rigs are not specific to just the ‘tachycardia therapy’. they normally shut the whole thing off. this pts underlying appears to be a-fib with a BBB. not truly convinced of the TdP. His pacer still appears functioning so Im not certain the magnet therapy worked at all. He may have a pacer lead that has migrated and double check lead placement and obvious causes of artifact. Im not so quick to jump on the mag bandwagon just yet. May consider if it reoccurs.

  • Tom says:

    I did not have the energy to read all the post, so I hope I not repeating. I treated a similar patient, we hung 150mg of Amio and ran it over 10min. It worked extremly well. It doesn’t look like the medics gave aspirin. ASA is the best medication we have in the case of MI(decreases morbidity and mortality by 60%). This person obviously has cardiac damage hints the vtach causing his ICD to fire.

  • Tom B says:

    Amy K. –

    Magnet application should not affect the bradycardia functions of an ICD. If that were the case, a pacemaker dependent patient could die if they wandered into a magnetic field. So the pacemaker would need to be turned off by RF telemetry (being hooked up to a laptop computer and specifically told to turn off — probably complete with a “ARE YOU SURE YOU WANT TO DO THAT?” screen). The worst that should happen is that a pacemaker (without an ICD) would convert to a more primitive mode. For example, switch from DDD to DOO (dual chambered pacing at a fixed rate without inhibition). So in most cases magnet application will only affect the tachy therapy of an ICD but you should ask to see the patient’s ID card and read the back.

    Tom

  • Tom B says:

    Tom –

    I’m not against ASA for this patient (although I’m not convinced he’s having a heart attack). As for the mortality benefit of ASA for acute STEMI I think it’s more along the lines of 25% according to ISIS-2. Update: Here’s the language from the abstract: “[A]spirin alone … produced a highly significant reduction in 5-week vascular mortality: (9.4%) vascular deaths among patients allocated aspirin tablets vs 1016/8600 (11.8%) among those allocated placebo tablets (odds reduction: 23% SD 4; 2p less than 0.00001).”

    http://www.ncbi.nlm.nih.gov/pubmed/2899772

    Tom

  • RM says:

    Great case! First look I saw also looked like there might be some polymorphic vtach… If I had a magnet I would certainly try it, to get a clearer rhythm strip. This did bring up a question for me, can you get post shock cardiac dysfunction from an ICD?

    In the absence of a magnet, I would try the mag, then lido or amiodarone. I agree amio is sketchy with qt prolonging effects, but I wonder if giving mag with no resolution would exclude a diagnosis of TdP. Any thoughts?

    If I was able to, and the pressure was good, I might give a whiff of versed or if I was a little more concerned maybe some fentanyl for pure analgesia.

    Putting on external pads would also be top of the list along with general supportive care (o2 iv etc).

    If I was unable to get a clean 12 lead, I would also consider ASA as it is unlikely to harm, and an MI might be the underlying cause of the arrhythmia.

  • Midwest Medic says:

    Interesting case. Working my days off in a Heart ER I have sen cases like this many times and cardiologists generally approach them the same.

    Step 1, apply the magnet, but be sure to be ready to remove it when the pt goes unconscious.

    Step 2, IV, 12-lead, o2, amiodarone bolus, something for pain

    Step 3, if the amnio doesn’t work have seen a variety of other drugs (lido, mag, and even ready recently about someone getting bretylium as a last resort which worked).

    Usually the cause of these events is the pt stopped taking their home amnio.

  • Chris says:

    Definitely agree with an amio or lido drip, further more agree with tom’s idea of “ARE YOU SURE YOU WANT TO DO THAT”. I might transmit the 12-lead and get a second opinion

  • christopher m tanerillo says:

    -no magnets in my system.
    -Pads out and ready
    -02 maintaint sp02 above 96%, 12 leads xserial, IV x2 if poss, NS hung and 150ml/hr at this time.
    -Consult med cont
    -He is likely going to receive more shocks in my care,
    -Sedate- versed, or a narcotic. I am not allowed to combine the two in my system. Ill prolly request it via cell phone anyway. And i think benzo and pain managment are both required but what do i know.
    -I thought it looked more polymorphic so i was tempted for mag as first line. However after reading above perhaps this is careless and amioderone 150mg over 10 is better indicated first line? I know it generally has possitive effects on ventricular rhythms, and in this case if patient is on Dig i dont mind messing up his values if we can fix the bigger problem, the hospital can fix the dig 😉

  • Janet says:

    You can call any device company and ask them to have your local rep bring you some magnets. I’ve seen many of you correctly stating that the magnet temporarily deactivates the ICD. As for a magnet applied to a pacemaker, it forces pacing in DOO or VOO mode at a higher rate and output. The rate induced corresponds to the battery voltage of the device and gives an idea of longevity.

  • Janet says:

    Also forgot to mention that many antiarrhythmic drugs can affect the defibrillation threshold. Since they only observed one shock, and from the looks of the initial tracings, it is also likely that he is going in and out of Torsades. I’ve seen MANY electrograms from the ICD that show patients being shocked out of VT only to go back in it seconds or minutes later.
    It doesn’t necessarily mean the device is defective or that a lead needs to be repositioned (the former of which is extremely unlikely and the latter very unlikely as well).
    Thanks guys for all you do! It sounds like a lot of you really know your stuff and I enjoy reading your case studies and comments!

  • James Combs RCIS, RCES, EMTP says:

    Wow, do we as Paramedics need some education regarding implanted devices i.e. Pacemakers, ICDs, and BiVentricular devices. The complexity and functions of implantable devices in today’s world have made them more difficult than ever for the Allied Health Care provider to understand. As a Paramedic with 32 years of experience and a Invasive Cardiovascular Electrophysiology Specialist for over 20 years I can safely say one of the more challenging patients we have to deal with is the patient with a malfunctioning implanted device. In regards to the patient in question, the most appropriate treatment is application of a magnet over the device which suspends detection in all manufacturers devices but still allows for pacing if necessary. This is a simple piece of equipment that should be on every ambulance in the World. Almost all device manufacturers have had alerts or recalls on either their generators or leads that have placed several hundred thousand patients at some risk for this same scenario. Good patient assessment, IV access, magnet application, 12 Lead EKG monitoring with ongoing assessment and transport may be all that is necessary for this patient. Don’t over analyze the situation. Magnesium for Torsades and Amiodarone for Monomorphic VT could be considered, but remember drugs are not always the answer and can sometimes do more harm than good. You may not be able to identify the cause of frequent shocks, but understanding the possibilities should be considered. MI, VT storm, lead fracture, lead insulation break, metabolic derangement, inappropriate device detection of rhythm etc… This patient needs interrogation of her device for troubleshooting and possible reprogramming. She needs a metabolic panel for determination of electrolyte abnormalities including a magnesium level. She may potentially need antidysrhythmics, device and or lead revision or percutaneous ablative therapy. In the setting of an acute MI she needs the Cath Lab for emergent revascularization. Again, these patients are extremely challenging but very manageable if the paramedic has a better understanding of implantable devices. Magnet application for frequent ICD shocks is safe and effective as long as EKG monitoring and patient assessment are ongoing during transport. If the patient develops VT or VF, remove the magnet and let the ICD do its job. If no change in rhythm or evidence of SVT or Atrial Fibrillation with RVR leave the magnet in place and monitor patients level of conciousness and hemodynamics. My comments or suggestions should in no way be misinterpreted as a guideline, protocol, or standard of care. Any questions or comments feel free to contact me at jhcombs@comcast.net

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