Morning Report

Morning Report: Not your typical pulselessness…the LVAD Pt.

Resident Presenter: Ndabezinhle (Nda) Mhlophe, MD

Topic: The pulseless patient. A basic approach to the LVAD patient in the ED.

 Summary:

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

 Learning Points:

  • 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.       

EBM Articles:

  • 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.
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