Mechanical Circulatory Support Mechanical circulatory support MCS encompasses Left ventricular assist devices LVAD Total artificial heart TAH Implanted artificial pumps to support circulation ID: 912706
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Slide1
EMS Care of the Mechanical Circulatory Support (MCS) Patient
Slide2Mechanical Circulatory Support
Mechanical circulatory support (MCS) encompasses:Left ventricular assist devices (LVAD)Total artificial heart (TAH)Implanted artificial pumps to support circulation.
Slide3MCS Complexities
Assessing and managing MCS patients can be challenging and may not follow routine EMS protocolsWe strongly encourage first-responders to utilize the center’s hotline of the implanting hospital before and during every MCS patient encounter and/or transport
Slide4Center Contact Numbers
Slide5A VAD is a Mechanical Circulatory Support (MCS) device designed to restore blood flow and improve survival, functional status, and quality of life for those suffering from advanced heart failure.
The device is implanted in parallel with the heart, taking over a majority of its circulatory functionMultiple devices in useNo age limitLVAD Overview
Slide6Left Ventricular Assist Device (LVAD) Indications
Sometimes implanted as a temporary treatment, and sometimes used as a permanent solution to very low cardiac output.Heart failure while awaiting heart transplantUntil end of life
Slide7Left Ventricular Assist Device (LVAD)
Only supports the Left side of the heartPatient population: NYHA Class IIIb/IV Heart Failure, EF <25%, not tolerating GDMT, poor quality of life, Inotrope Dependent, Left Ventricular failureWhen responding to a call for an LVAD patient, ALWAYS call the MCS Coordinators- regardless of the patient’s program
Slide8How it Works
Blood continuously flows through the device, and out to the rest of the body to circulate oxygenated blood to organsThe pump is inserted into the Left Ventricle and assists blood flowDoes not take over ALL the workBlood flow runs parallel to native flowThe heart still beats- just maybe not every beatExternal power runs through the system controller, up the driveline and to the LVAD pumpAKA these patients ALWAYS need to be on external power
Slide9All LVAD’s have internal and external components:
LVAD Pump Driveline System ControllerExternal Power**The Driveline must ALWAYS be connected to the System Controller****The System Controller must ALWAYS be connected to external power sources**1. LVAD Pump2. Driveline3. System Controller4. External Power
LVAD Components:
HVAD
Slide10LVAD Special Considerations
LVAD patients are unique and require specialized careRoutine assessments such as blood pressure, pulses, and pulse-oximetry may not be unattainable Chest compressions are usually not indicatedLVADs have both internal and external components, a controller and power sources that operate the implanted pump though a single driveline.The driveline will exit from the abdomen. It is important never to cut this line.
Slide11LVAD Patient Assessment
Head to toe assessmentEnsure pump is onAuscultate the left chestGreen spinning arrows/lights on controllerVital signs may differBe cautious of the drivelineUse the family/caregiversCall the Coordinator
Slide12LVAD Patient assessment
The most reliable indicator of perfusion will be to assess clinical indicators of perfusion rather than the patient’s vital signs.Mental statusColorCapillary refill
Slide13Vital Signs
Blood PressureShould be taken with a manual BP cuff. Automatic BP machines will be unreliable. SpO2Number may be inaccurate d/t continuous flowPleth waveform is accurate
Look for other clinical signs of hypoxia.
Pulse
May not have palpable pulse
Occurs when blood is exiting the aortic valve with each beat
ECG
Has typical ECG tracings
Pacemaker/Implanted defibrillator often in place
May have artifact from LVAD
May tolerate dysrhythmias better
Can defibrillate if needed
Slide14Patient Assessment cont.
EKG is typically unaffectedPatients are at high risk for bleeding complications due to blood thinner useTraumaFallsGI bleedRemember, that the coordinator will be able to assist in performing patient assessment.
Slide15LVAD Patient Rhythm Assessment
Because they have a blood pump, VAD patients may be stable in V-Tach or V-FibVAD flows may be affected by dysrhythmiasPersistent dysrhythmias are treated after contacting the VAD coordinatorMany VAD patients have an ICD / PacemakerIf patient’s ICD delivers a shock, notify VAD CoordinatorOkay to defibrillate & cardiovert VAD patients per ACLS protocolOkay to administer anti-arrhythmic medications per ACLS protocol
Slide16VAD Patients with Dysrhythmia#1 =
Contact VAD coordinator#2 = Treat the patient, not the monitor!
Slide17Common 911 calls
Stroke Heart failure exacerbation Falls Equipment failure
Slide18LVAD Patient Stroke Assessment
All VAD patients are on anticoagulation medicationsThey are at high risk for embolic or hemorrhagic stroke. Level of consciousness may deteriorate rapidlyBecause patients are already anti-coagulated, they do not follow routine stroke protocolThe priority for destination would be the patient’s home center.
Slide19VAD Patients & Potential StrokeKey point:
Transport these patients to their VAD center, not the closest stroke center!
Slide20Heart Failure
LVAD patients still have heart failureMay have symptoms related to hypovolemia or volume overload. Assess volume status as part of your evaluation.Pitting edemaLung crackles Shortness of breath/orthopnea
Slide21Heart Failure cont.
Patients may require airway management or ventilatory support.May consider CPAP as neededDo not give nitroglycerine to LVAD patients. Fluid bolus as indicated, in conjunction with LVAD coordinator consultation.
Slide22Falls and Trauma
Patients are at risk from bleeding due to chronic anticoagulation. Follow local protocols for transport decision. If time/situation allows call LVAD coordinator to discuss options for transport and LVAD assessment.
Slide23Equipment Failure
Primary equipment malfunction is extremely rare. Focus on patient assessment before any pump evaluation. Look first at the screen which may indicate if there is a device malfunction. The hotline will be available to help with pump assessment/troubleshooting if this is necessary. Assess pump function by auscultation.
Slide24Critical VAD ConnectionsNever disconnect both power sources! Never disconnect driveline!
HeartWare HVADHeartMate II/3
Power
Driveline
Power
Power
Power
Driveline
Slide25Care of the equipment and driveline
Use caution when cutting and removing clothes to avoid damage to driveline. Always ensure there is no stress or twisting of the driveline when loading and transporting the patient. Please bring the extra equipment in the backup bag with the patient.
Slide26VAD complications: infection
LVAD patients are at risk of infection due to chronic heart disease LVAD patients should always have a sterile dressing covering the driveline exit site in the lower abdomen. Do not lift up or look under the dressing. For EMS providers ensure there is no tugging or stress on the driveline to prevent infection.
Slide27Alarms
Look at the system controller first and call the coordinator. Regardless of the device the system controller will have a message describing the alarm and basic troubleshooting. Most important, ensure there are two power sources and driveline connected to the device.
Slide28LVAD controllers
ALARM SILENCE
Alarms have symbol
and message on screen
Yellow (beeps)
Pump is ON
Red (steady tone)
Pump may be OFF
Slide29LVAD Emergency Response: IS THE PUMP RUNNING?!
(Look for lights on the controller +/- Auscultate over the pump)
Slide30Total Artificial Heart (TAH)
Pump surgically implanted to provide biventricular circulatory support
Slide31VAD versus TAH
Slide32TAH Emergency Response: IS THE PUMP RUNNING?!
If TAH pump is not running, the patient cannot survive this. There are no resuscitative measures to perform.
Call coordinator & call base hospital as this will fall outside termination guidelines.
Slide33Questions?