👉as a bridge to recovery when cardiac function is temporarily diminished (i.e., myocarditis)
👉as a bridge to cardiac transplantation
👉as destination therapy for patients who are not candidates for cardiac transplantation
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➡️ ED Evaluation of a VAD Patient
👉Begin with assessment of the patient’s airway, breathing, and circulation
👉Pulse - pulse is often absent or markedly diminished (current VA devices deliver a continuous flow of blood)
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👉 Blood Pressure - Noninvasive systolic and diastolic blood pressure measurements may be inaccurate or simply not obtainable.
👉 The mean arterial blood pressure (MAP) can be obtained with a blood pressure cuff and Doppler ultrasound over the brachial or radial artery.
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👉 Chest Auscultation - the absence of an audible hum suggests catastrophic VAD dysfunction and the need for immediate resuscitation.
👉 Echocardiography (echo) - can be used to evaluate for pump thrombosis, right ventricular (RV) failure, and “suction” events.
➡️ Atrial or Ventricular Dysrhythmias in VAD Patients
👉 Obtain an ECG early to evaluate for dysrhythmias.
👉 Common etiologies for dysrhythmias include hypovolemia, electrolyte derangements, and myocardial ischemia.
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➡️ Pump Thrombosis
👉 Pump thrombosis reduces cardiac output.
👉 VAD patients with suspected thrombosis should receive anticoagulation with heparin.
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➡️ Bleeding in VAD Patients
👉 All VAD patients are placed on anticoagulant and antiplatelet medications to decrease thromboembolism
👉 VAD patients develop an acquired von Willebrand syndrome due to shear forces from the VAD
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👉 Decreased pulse pressure of the continuous flow contributes to arteriovenous malformations, especially in the jejunum
➡️ Acids cause coagulative necrosis, which results in a self-limiting burn pattern
➡️ Alkaline materials induce liquefactive necrosis with diffusion into deeper layers of the injured mucosa. Even low concentrations of alkaline ingestion can cause extensive injury.
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➡️ Caustic Ingestion can provoke injury from the mouth, the airway, down through the esophagus to the small intestine.
➡️ Long-term complications can lead to strictures and an increased risk of esophageal cancer.
➡️ Boerhaave syndrome is a spontaneous rupture of the esophagus from barotrauma related to retching or any sudden increase in intraabdominal pressure against a closed glottis.
➡️ Boerhaave syndrome should be suspected in any patient who presents with retrosternal chest pain, neck pain, or epigastric pain, especially if it began after an episode of severe retching or bearing down against a closed glottis (weight lifting, defecation, childbirth, etc)
➡️ Additional critical diagnoses to consider that can be detected with ECG:
👉Ventricular Preexcitation (WPW)
👉Brugada syndrome
👉Long or short QT syndromes
👉Hypertrophic Cardiomyopathy
👉Arrhythmogenic right ventricular dysplasia
👉Catecholaminergic polymorphic VT
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➡️ Ventricular Preexcitation (WPW)
👉 PR segment < 120 ms
👉 QRS complex > 110 ms
👉 Slurred upstroke of the initial part of the R wave (delta wave)
➖ Type A: delta wave in all precordial leads, R > S in lead V1
➖ Type B: negative delta waves in leads V1 and V2
➡️ Diuretics may not be the preferred initial therapy for those patients with vascular failure, who are often euvolemic, or those with cardiogenic shock, who are often hypovolemic.
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➡️ In these patients, the emergency provider should first optimize preload and afterload reduction with the use of noninvasive positive pressure ventilation (NPPV), nitrates, or inotropes as indicated.