Resident Presenter: Ndabezinhle (Nda) Mhlophe, MD
Topic: The pulseless patient. A basic approach to the LVAD patient in the ED.
75 y.o LVAD patient presented to the ED c/o progressive SOB, decreased fluid and food intake, ongoing dizziness and fatigue. Prior ED visit (May 2015) with chest pain, work up ruled out cardiac etiology.
Vitals (per chart): BP 91/52 | Pulse 74 | Temp(Src) 98.1 °F (36.7 °C) | Resp 18 | SpO2 100%
PE: No S1/S2/peripheral pulses/edema, continuous LVAD tone on auscultation; guaiac positive
Labs: Hgb 7.1
- Current devices work by continuous blood flow, which will not produce a traditional pulse pressure waveform.
- Pts should have a mean arterial pressure (MAP) measured, normal = 70-90mmHg.
- Acute decompensated heart failure may be due to device failure or worsening of the intrinsic cardiomyopathy.
- The crashing Pt: consider cannula dislodgement, massive thrombosis & tamponade…Otherwise follow regular resuscitation algorithms. How about chest compressions? Controversial subject, current manufacturer recommendations are not to perform CPR. Early consultation with LVAD team is important.
- Aldrich, Thomas K., et al. “Pulseless oximetry: A preliminary evaluation.”CHEST Journal (2015).
- Shinar, Zachary, et al. “Chest compressions may be safe in arresting patients with left ventricular assist devices (LVADs).” Resuscitation 85.5 (2014): 702-704.