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EMS Care of the VAD Patient
ADHS BEMS Education & PMD CommitteesApril 2018
VAD Complexities
Assessing andmanagingVADpatients can be challenging and may not follow routine EMSprotocolsWestrongly encourage first-responders to utilize the VAD Hotline of the implanting hospitalbefore and duringeveryVADpatientencounter and/or transport
Banner University Medical Center-Phoenix (BUMC-P)
RN VAD Coordinator on-call24/7Cell602-819-7910Office 602-839-5137
Banner University Medical Center-Tucson (BUMC-T)
VAD # = 520-694-6000Ask for Artificial Heart Coordinator On-Call
Dignity St. Joseph’s Medical Center
VAD # = 602-406-8000Ask for VAD NP on-call
Mayo 24 HRVAD HOTLINE
TheVADHotlinewill connectyou to a VADCoordinator in under 2 minutesThe24 Hr VADHotlineis for patients, caregivers, and first responders to use as a consult service for emergent and non-emergent needs.With calls involving 911,patientsand caregivers are instructed to givefirst responders the phonewhen you arrive so EMS is immediately in communication with aVADexpert that is familiar with details about thepatientIf 911 call comes from a bystander, an identifyingstickerwill be on the Controller withbasic patientinformation and VAD Hotline number.
Mayo VAD Coordinator: 480-342-2999
A VAD is a MechanicalCirculatorySupport (MCS) device designed to restore blood flow and improve survival, functional status, and quality of life for those suffering from advanced heart failureThe device is implanted in parallel with the heart, taking over a majority of its circulatory functionMultiple devices inuseNo age limit
VAD Overview
Ventricular Assist Device
Implanted in heart failure patientsAugmentsthe function of the ventricles in circulating bloodSometimes implanted as a temporary treatment, and sometimes used as a permanent solution to very low cardiac output
Ventricular Assist Device (VAD)
There are 2 indications for implanting an LVAD:Bridge to TransplantThe patient must meet criteria to be listed for a heart transplantThe VAD is taken out at time of transplantDestinationTherapyThe patient does not qualify for a heart transplant but meets criteria for Destination TherapyThe patient lives the rest of their life with anVADBridge to RecoveryVAD for a few days or weeks, provides temporary supportEx.Patient with post partum cardiomyopathy
VAD Special Considerations
VAD patients are unique and require specialized careRoutine assessments such as blood pressure, pulses, and pulse-oximetry may not be unattainableChest compressions areusuallynot indicatedThe patients carry external equipment: a controller and power sources that operate the implanted pump though a single driveline

VAD Patient Assessment
Attemptto auscultate over theapex of the heartfor a “whirling” or “smooth, humming” sound indicating that the VAD is workingA cable exits the abdominal wall that connects the device to power and the control unitMany VAD patients also have an implanted cardiac defibrillator
Auscultate over apex
VAD Patient Assessment
Patient Assessment cont.
EKG is typically unaffectedPatients are at high risk forbleeding complicationsdue to blood thinner useTraumaFallsGI bleed
VAD Patient Rhythm Assessment
Because they have a blood pump,VADpatients may be stable in V-Tachor V-FibVADflows may beaffectedPersistentarrhythmias aretreatedaftercontacting the VAD coordinatorManyVADpatients have an ICD /PacemakerIfpatient’s ICD delivers a shock, notify VAD CoordinatorOkayto defibrillate&cardiovertVADpatients per ACLS protocolOkayto administer anti-arrhythmic medications per ACLSprotocol
VAD Patients with Dysrhythmia
#1 =Contact VAD coordinator#2 =Treatthe patient, not the monitor!
VADPatientNeuro Assessment
AllVADpatients are on anticoagulationmedicationsThey are athigh risk for embolic or hemorrhagic stroke.Levelof consciousness may deteriorate rapidlyBecause patients are already anti-coagulated, they do not follow routine strokeprotocol
VAD Patients & Potential Stroke
Keypoint:Transportthese patients to their VAD center, not the closest strokecenter!
VADManagement
Allow the patient and caregiver to guide your interaction with the deviceKeep batteries and controller within reach and secured to the patientAdminister fluid boluses and vasopressors as you would with any other patient as indicated by signs of inadequateperfusionDoNOTadminister nitroglycerin to VAD patients
When in doubt. . . give a fluid bolus
Assessingfor signs ofHypovolemia
Caution with clothing removal
Use caution when cutting and removing clothes, to avoid damaging the device
Driveline Exit Site - Sterile Dressing
VAD patients should always have asterile dressing covering the drivelineexit site in the lower abdomen.The dressing should not get wet.
VADcomplications: infection
Many hospital admissions in VAD patients are secondary to infection, not cardiac problems.Assess for signs of infection (especially at the insertion point) or sepsis
VADManagement
#1 = Consultthe patient’s VAD coordinatorVerifyif chest compressions are indicated with the patient’s specific deviceConsult familyView VAD identification cardUseelectrical therapy as you would with any otherpatientAvoidplacing the pads directly over the device (consider anterior-posterior pad placement)
LVAD Patient Management
PRELOAD

VolumeBlood PressureCVP / PVRRight Heart FunctionValvular FunctionRhythm
AFTERLOAD
SVRMAP 65-85
ANTICOAGULATION
CoumadinASAINR 2-3
PUMPSPEED
Set RPM toBLOOD IN = BLOOD OUT
What if I hear an alarm?
HeartWareFlashing Red (High-Critical Alarm)VAD stoppedCritical BatteryController has failedWhat should you do?First, check your patient and treat as indicatedConnect the driveline, replace the batteries, or change the controller as directed by the VAD coordinatorAlways change the batteries one at a time, at least one must be connected at all times
What if I hear an alarm?
ThoratecHeartMateIIRed Heart Alarm – there will be a red heart warning light on the system controller & a steady audio tonePump flow is less than 2.5 LPM (inadequate to meet the patient’s condition)Pump has stoppedPercutaneous lead (driveline) is disconnectedPump is not working properlyWhat should you do?Check your patientMake sure the system controller is connected to the percutaneous lead (driveline)Treat any sources of low flow or shock (bleeding,hypovolemia,tamponade, etc)Contact VAD coordinator
Total Artificial Heart (TAH)
Pump surgically implanted to provide biventricular circulatory support
VAD versus TAH
Abbott-Thoratec HeartMate 3
HeartWare System
Implanted Pump
Driveline
Battery
Battery
Controller
HeartMate II System
Implanted Pump
Battery
Battery
Controller
Driveline
Critical VAD ConnectionsNever disconnect both power sources! Never disconnect driveline!
HeartWare HVAD
HeartMate II
Power
Driveline
Power
Power
Power
Driveline
External VAD Components
Patients have options for carrying their external equipment to best suit their comfort and lifestyle
Ensure that the equipment is protectedat all times withno stress on the driveline
Patients will have an additionalsupply bag for their extra batteries andbackup Controller close at hand.This bagshould always accompany the patient ontransport
External VAD Components
The Controller
For HeartMate 2 and 3press MENU buttonto access parameters
ALARM SILENCE
Alarms have symboland message on screen
Yellow (beeps)Pump is ON
Red (steady tone)Pump may be OFF
HVAD®Controller: Display Overview
AC/DC Indicator
Battery Indicator 1
Alarm Indicator
Battery Indicator 2
Power Source 2
Power Source 1
Power Management
Patients are responsible for managing their powerThey have 6-8 batteries in rotation and a home chargerBatteries generally last 8 – 14 hours perpairExchangedone at atime, so onepower source is always connectedto the ControllerPatients only need to be on A/Cpower when sleeping
Assessing Pump Flow
Flow (L/min)Average adult Cardiac Output at rest is ~ 5 L/minBody size / blood volume effects pump flow potentialThe Flow parameter is an estimateFlow will mainly fluctuate with changes in activity, body position, and blood volumeHyper / hypovolemiaOther physiologic conditions can also effect flow:Right Heart FunctionRhythm disturbancesHypo / hypertensionValvular functionPulmonary hypertensionThrombosis
Pump Flow
Assessing Pump Flow
Routine LVAD Call / Transport
As soon as possible,engageVAD Hotlineof implanting facility
If indicated, obtain ECG,administer O2, start IV perstandard protocol
You’ll be unable to obtain anaccurate BP(without doppler),pulse, and pulse-oximetry.Visual assessment of presenting signs and symptoms is always reliable
If trained family member orcaregiver is present, allow themto ride in ambulance with patient if possible
Ensure that bag containingback-up LVAD equipmentaccompanies patient on transport
In consult with theVAD Hotline,transport to nearest appropriatefacility.
VADEmergency
Continue airway support / rescue breathingAssess RhythmICD firing – AmiodaroneV-tach / V-fib – Amiodarone,Cardioversion per ACLS protocolAssess Doppler BPEstablish IV accessUse Code Drugs as indicated
Airway/ Rescue Breathing /O2Call patient’s VAD Hotline

Patient Unconscious
Verify
Rule-outVADpower or driveline disconnectRe-connectif disconnectedVerifyVADis runningListen for whirr of the pump over theapexIf an alarm is present, silence it and consultwith the VAD Coordinator on-call
PUMP ON
PUMP OFF
Note:VAD Equipmentfailure is very unlikely
Life-support measures withCPR only after contacting VAD coordinator

Transport

VADHotlinewillhelp triagethe equipmentandadvise onany equipment-relatedinterventions
PUMP ON
Note: Verifying PUMP ONis like confirming a pulseon anVADpatient
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