VENTRICULAR ASSIST/Heart Assist DEVICES BEST PRACTICES GUIDELINE Purpse: T prvide infrmatin and directin regarding the care f patients wh have a Ventricular Assist Device (VAD) r a Ttal Artificial Heart. Overview f VADs and Heart Assist Devices: The VAD assists the native ventricle pumping actin and prvides the cardiac utput needed t survive. These devices are either pulsatile r cntinuus flw (nn-pulsatile). They are further divided int Left Ventricular Assist Devices (LVAD), Right Ventricular Assist Devices (RVAD), r bth ventricles (BiVAD). The mre cmmn device is a cntinuus flw pump lcated in the patient s thrax attached t the patients left ventricle and arta (LVAD). The assessment f patients with these devices will nt be instinctual, as many f the nrmal assessment parameters will nt be available r their results will be seemingly cntradictry (see Patient Assessment belw). A Left Ventricular Assist Device des nt preclude the patient frm getting right sided heart failure, e.g., Right Ventricular Infarctin. Treat per yur lcal prtcls. The Syncardia Ttal Artificial Heart includes the actual remval f the heart itself. The device is pulsatile, but there will be n meaningful ECG. NTG is cntraindicated in this ppulatin. Cntact VAD Crdinatr fr directin n assessing these patients. Pre-Arrival/On Scene Cues: Infrmatin regarding the type f device, the implantatin hspital, and/r the VAD Crdinatr cntact telephne number may be available in yur Cmputer Aided Dispatch (CAD) System. There may be a tag n the device, n the refrigeratr, r n a medical alert bracelet with the name f the device and cntact infrmatin fr the VAD Crdinatr at the center that implanted the VAD. This tag r bracelet may be clr cded t crrespnd with the devices listed in Appendix A (Mechanical Circulatry Supprt Organizatin EMS Guide, January 2012). Assess fr presence f a DNR, POLST r Advance Directive.
Initial Assessment First ASSESS THE PATIENT, nt the device. The reasn fr the call may r may nt be a prblem with the VAD. VAD patients can and frequently d have ther medical cnditins besides a weak heart. Patients with a cntinuus flw VAD typically have n discernible pulse r bld pressure. Because there is n pulse, utilize ther parameters fr patient assessment (level f cnsciusness, skin signs, capillary refill, etc.) Als because f the lack f a palpable pulse, pulse ximetry will be either absent r unreliable. Utilize the American Heart Assciatin s C-A-B recmmendatins, with ne additin: C = Circulatin/Cnnectins (device) A = Airway B = Breathing Secnd, assess t see if the device is wrking. If the patient has a cntinuus flw VAD (nn-pulsatile), yu will be able t auscultate the left upper quadrant f the patient s abdmen fr the hum f the VAD, which can help direct the apprpriate actins. A pulsatile VAD will make an audible sund withut auscultatin. Pulsatile VADs are usually lder devices which pump bld via pulsatile mechanism, generating a peripheral pulse. Determine if the device has pwer. If the device has pwer it des nt necessarily mean that it is wrking, s the previus step is very imprtant. If the device has pwer, yu will see a green light n the HeartMate II, the mst cmmnly implanted device On the HeartWare device, the display will clearly tell yu the Liters per Minute (LPM) f bld flw. If yu are unsure what type f device it is, lk fr the tag (which may be clr cded t be in accrdance with the VAD EMS Guide see Appendix A) n the cntrller, in the patient s wallet, r n a medical alert bracelet. The patient and/r family/caregiver can als tell yu what device the patient has. Check the VAD fr secure cnnectins and that the batteries are charged and functinal. Remain patient-centric. Check the VAD as directed, but remain aware f hw yur patient is ding clinically. Deliver rutine medical care as required.
If the pump is pumping then the prblem is with the patient, nt the device. D ABCs in cnjunctin with yur VAD assessment. Sidestream r mainstream end tidal capngraphy will read accurately. This will be useful in assessment f these patients. Cntact/Assistance: Fllw yur lcal prtcls r cntact yur base hspital fr rders cncerning patient care. If a caregiver is present, utilize his/her knwledge. The patient and their caregiver are the experts n scene fr all issues related t the VAD. Listen t their directins regarding VAD device management until yu are able t cntact the VAD Crdinatr. Patients and their caregivers are taught t call 9-1-1 in an emergency and then page the n-call VAD Crdinatr immediately. The VAD Crdinatr has experience and can help yu decide the best curse f actin. As early in the call as pssible, cntact the fllwing: Base hspital The nurse/physician may wish t directly cntact the VAD Crdinatr t crdinate the care f the patient with them. VAD Crdinatr He/she will talk yu thrugh the assessment f the equipment. Check the patient s wallet card r labels n equipment fr infrmatin n cntact infrmatin fr the VAD Crdinatr. Only the base hspital is legally allwed t give rders regarding patient care. The VAD Crdinatr can help yu t assess the device itself. Receiving hspital An early ring dwn is critical t help the facility prepare fr this highly specialized patient. If the VAD is the prblem: If any alarms are ging ff, r if the device appears nt t have pwer: Recnfirm the cnnectins are secure and that the batteries are charged. Check that the driveline is cnnected t the cntrller. Exert great care nt t disldge the driveline. Utilize the caregiver r patient s knwledge t cntinue checking the VAD. Alarms: Always check and treat yur patient first. Thratec HeartMate II: Red Heart Alarm
There will be a red heart warning light n the system cntrller and a steady audi tne. Pump flw is less than 2.5 LPM (inadequate t meet the patient s clinical cnditin). Pump has stpped Percutaneus lead (driveline) is discnnected Pump is nt wrking prperly. Check yur patient. Make sure the system cntrller is cnnected t the driveline (als called the percutaneus lead. Handle with great care) Make sure the system cntrller is cnnected t a pwer surce. Treat any surces f lw flw r shck (bleeding, hypvlemia, tampnade, etc.) Cntact the VAD Crdinatr, wh may direct yu t change the system cntrller t the backup cntrller. Lw Vltage Alarm (Red Battery Alarm) Yu will hear a cntinuus alarm. There is less than 5 minutes f battery pwer remaining Vltage is t lw The system cntrller is nt getting enugh pwer frm the pwer mdule. Immediately replace depleted batteries with a new, fully charged pair. ALWAYS change batteries ne at a time. If batteries are nt available, switch t pwer mdule, pwer base unit, r emergency pwer pack. The cntrller must be cnnected t a pwer surce at all times. Batteries r pwer must be changes ne lead at a time t prevent the pump frm stpping. Nte: Pump speed will gradually decrease t Pwer Saver Mde until the cnditin is reslved and the alarm clears. N Pwer Alarm Yu will hear a steady, audible tne, but will see n lights n the system cntrller. System cntrller is nt receiving pwer.
Make sure the system cntrller is cnnected t 2 batteries r a single pwer surce Batteries Pwer Mdule Pwer Base Unit Emergency Pwer Pack If alarm cntinues, switch t a different pwer surce. Cntact the VAD Crdinatr, wh may direct yu t change the system cntrller t the backup cntrller. Lw Vltage Advisry Alarm (Yellw Battery Alarm) Yu will see a yellw battery warning light and hear an audible tne f ne beep every 4 secnds. There is less than 15 minutes f battery pwer remaining. The vltage is t lw The system cntrller is nt getting enugh pwer frm the pwer mdule r pwer base unit. Immediately replace depleted batteries with a new, fully charged pair. ALWAYS change batteries ne at a time. If batteries are nt available, switch t pwer mdule, pwer base unit, r emergency pwer pack. At least ne battery must be cnnected at all times. HeartWare Flashing Red (High Critical Alarm) VAD stpped, critical battery, r the cntrller has failed. First check yur patient and treat as indicated.. Cnnect the driveline, change the cntrller, r replace battery(ies). Flashing Yellw (Medium Alarm) Cntrller fault, high watts, electrical fault, lw flw, r suctin type event. Call the VAD Crdinatr Slid Yellw (Lw Pririty Alarm) Lw battery, pwer discnnected
Replace batteries, ne at a time Recnnect the pwer. If the alarm stps nce yu have made the adjustment, the equipment prblem is slved. Check yur patient. Patient Assessment Pints: Patients with a cntinuus flw VAD typically have n discernible pulse r bld pressure. Pulse ximetry may nt functin r it may be inaccurate. Autmated bld pressure devices are nt accurate and manual bld pressures usually cannt be btained in patients with a cntinuus flw VAD. A Dppler device can be used t btain a mean arterial bld pressure (MAP) in these patients. Having a Dppler device is nt feasible in the prehspital area. Hwever, the patient s caregiver may have ne and be able t btain a mean arterial bld pressure. The ideal range fr this bld pressure is 70 90 mmhg MAP. The 12-Lead ECG r heart mnitr will shw the patient s native heart rhythm and will nt necessarily reflect the patient s circulatry functin. Because f this, the patient may ptentially be awake while in ventricular fibrillatin. Cntact yur base hspital fr directin. Be able t discuss with the VAD Crdinatr, physician, r Base hspital if the patient appears t be stable r unstable in this rhythm. Is the patient shrt f breath, have delayed capillary refill, pr skin signs, altered level f cnsciusness? If defibrillatin is necessary, cnsider pre-sedating the patient wh is awake. Fllw yur lcal EMS prtcls and/r base hspital rders. The vast majrity f these patients will als have an Implanted Cardiverter Defibrillatr (ICD) r a Pacemaker/ICD due t underlying ventricular dysrhythmias. Be sure t btain this crucial data. The VAD is prelad (filling vlume) dependent. Dysrhythmias that wuld affect prelad (e.g. supraventricular tachycardia, atrial fibrillatin with rapid ventricular respnse, ventricular tachycardia, and ventricular fibrillatin) need t be treated. VADs pump r wrk best with adequate patient vlume. Patient Treatment: All VAD patients shuld receive the fllwing care: Utilize the American Heart Assciatin s C-A-B recmmendatins with ne additin: C = Circulatin/Cnnectins(device) A = Airway
B = Breathing Standard airway management Oxygen as clinically indicated Pulse ximetry will nt measure r will nt be accurate in these patients. IV initiatin prepare fr rders fr fluid resuscitatin (minimum amunt initially delivered shuld be 250-500 mls, and then reassess the patient). Standard ACLS except CPR Cnsult yur lcal EMS prtcls r base hspital regarding whether t perfrm chest cmpressins r nt. Mrphine fr chest pain management and trauma is apprpriate. The use f Nitrglycerin (NTG) can dangerusly lwer bld pressure and wrsen their clinical cnditin due t the VAD s dependence upn prelad (filling vlume). Cntact yur base hspital fr directin regarding the use f NTG. Trauma patients: Spinal immbilizatin and/r splinting may need t be mdified t prtect the integrity f the VAD equipment. Be careful nt t pull r cut the driveline. Make sure all equipment is safely secured. Trauma patients are trauma patients first rather than VAD patients with a trauma. Let the base hspital knw that patient has a VAD and may be n anticagulants. VAD Cmplicatins: VAD patients experience a higher percentage f the fllwing cnditins: Altered Level f Cnsciusness/Uncnscius and apneic The patient needs t have ACLS instituted immediately per prtcl Check airway, institute breathing, then: Immediately check the cnnectins and listen fr hum Trublesht using the VAD EMS Guide, if available. Cntact the VAD Crdinatr. Be prepared fr the VAD Crdinatr t give yu directins fr restarting the pump and pssibly changing ut the system cntrller. Medical directin must always cme frm the base hspital. Hemrrhage Active bleeding/hemrrhage is t be treated fllwing standard prtcl and the patient transprted t the clsest apprpriate receiving facility.
Patients meeting Trauma criteria are t be taken t the clsest Trauma Center, and treated as trauma patients accrding t lcal prtcls. Strke Strke patients need t be transprted as usual per lcal prtcl Please nte that these patients have a magnet in the device and many times an ICD. They cannt underg an MRI study, but may underg a CT scan. Pass this infrmatin t the base hspital and t the receiving hspital, if different frm the base hspital. Sepsis/Septic Shck If yu feel that these patients have an infectin r are in septic shck, they need fluid resuscitatin and prmpt transprtatin t the clsest mst apprpriate receiving center. Dysrhythmias Dysrhythmias need t be managed accrding t standard ACLS prtcls. Where there is cnflict, fllw the LEMSA s prtcls. If defibrillatin r cardiversin becmes necessary, fllw the apprpriate treatment prtcl as there are n cntraindicatins. The pump is insulated and will nt be damaged. Mst f these patients will have an ICD If defibrillatin is necessary, mve the cntrller t the patient s right side, s it is as far away frm the electrical therapy as pssible. DO NOT discnnect the system cntrller frm the percutaneus lead (driveline) r stp the pump prir t delivering the shck. Dysrhythmias may affect the device and a red heart alarm may sund if the patient is in a lw-flw state (less than 2.5 LPM f bld flw, r inadequate t meet the patient s clinical cnditin). If the patient has a pulsatile VAD, there will be an external hand pump, which can be used in lieu f perfrming chest cmpressins. It can be fund in the patient s equipment. Ask the caregiver. The caregiver has been educated regarding the use f these devices. Yu may fllw the caregiver s instructins in prperly utilizing the equipment. Cntact the VAD Crdinatr at the implanting center as early in the call as pssible fr further directins regarding the device.
Transprt: When transprting these patients t the hspital, the VAD emergency bag, pwer mdule, pwer base unit, batteries, charger, and emergency pack must all be brught t the hspital. When pssible try t transprt the patient t the implanting hspital. If transprt t the center that implanted the VAD is impssible, transprt t the clsest VAD Center. If there is n VAD Center nearby, try t transprt t a hspital that has cardiac bypass capabilities. If the patient is in extremis, r if there is n VAD implantatin center r hspital nearby with cardiac bypass capabilities, transprt t the clsest apprpriate prehspital receiving center, per lcal EMS prtcls. Patient appears t be in shck (pr skin signs, delayed capillary refill, and/r altered level f cnsciusness). Patient s ECG shws a dysrhythmia that affects prelad (such as ventricular tachycardia, ventricular fibrillatin, supraventricular tachycardia, r atrial fibrillatin with rapid ventricular respnse). Whenever pssible, allw the caregiver t accmpany the patient in the ambulance r EMS airship t help facilitate care. Additinal Infrmatin: The VAD Crdinatr may give directins t the EMS prvider regarding the VAD equipment. Medical directin r destinatin decisins must be made by the base hspital. Remember t always check yur patient and treat the patient first rather than the equipment (the VAD r the Ttal Artificial Heart). A training PwerPint has been prvided fr each prvider agency and hspital which further details the care and management f the VAD patient. There are multiple vides available frm Thratec, ne f the device manufacturers, n their website, www.thratecu.cm. There is als an EMS Guide t VADs available n the varius devices at www.mylvad.cm, r in Appendix A f this dcument. Appendix A: Mechanical Circulatry Supprt Organizatin EMS Guide, January 2012 Appendix B: Just in Time Training Tl fr VADs