Left Ventricular Assist Device Management in the Emergency Department

Paul Trinquero, MD; Andrew Pirotte, MD; Lauren P. Gallagher, MD, MA; Kimberly M. Iwaki, MD; Christopher Beach, MD; Jane E. Wilcox, MD

Disclosures

Western J Emerg Med. 2018;19(5):834-841. 

In This Article

Management of the Unstable and Crashing Patient

When caring for an unresponsive or hemodynamically unstable VAD patient, one must emergently contact the VAD team while simultaneously stabilizing the patient. In a code, follow the conventional Advanced Cardiac Life Support algorithm including chest compressions, medications, and defibrillation as indicated. While there is a manufacturer warning regarding the risk of cannula dislodgment with manual chest compressions, the small body of available evidence suggests that this is rare.[27] Withholding cardiopulmonary resuscitation in this scenario is universally fatal. Chest compressions should be performed on a pulseless VAD patient in an attempt to perfuse vital organs, while troubleshooting the device and contacting the VAD team.

Pulse checks should include brachial artery Doppler for MAP and review of the VAD monitor for signs of mechanical failure as discussed above. Auscultate the heart to listen for the "whirring" sound of the device. If you cannot hear the device functioning, troubleshoot the controller, ensure adequate power supply, and check all device connections. If the patient is hypotensive and has low VAD flows, consider a quick bedside ultrasound to evaluate for hypovolemia vs. RV failure. If the patient is hypotensive with elevated VAD flows, consider pump thrombosis, and also sepsis (extreme afterload reduction from vasodilation leads to higher VAD flows). If you suspect device malfunction, advanced therapies such as extracorporeal membrane oxygenation should be considered, especially in younger patients who are heart transplant candidates without significant comorbidities.

Evaluation of VAD patients can be daunting, but focused clinical priorities – taken in the context of the implanted device – facilitate rapid and appropriate management of both stable and critically ill VAD patients. Regular review of available support sources and quick access to reference material can greatly improve the care of VAD patients in the ED. Given the evolving technology and increasing prevalence of VADs, the ED community would benefit from both VAD-specific training programs in residency training and continuing medical education curricula.

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