Question about internal defibs

I work on a cardiac stepdown unit and a majority of my patients have ICD's and PM's. I actually have taken care of a woman for the past few days who's ICD shocked her 27 times in one day (needless to say that's why she came to the hospital).

I say that if the ICD fires once or twice then just monitor the patient and alert the cardiologist of the occurence (could be that the pt had a run of V-tach and the ICD fired). If it happens more than that the patient should go to the hospital (especially if the firings happen one right after the other). The ICD could be malfunctioning or need to be adjusted.

AICDs are put in to prevent a pt from dying from a lethal rhythm. Period. They dont fix the problem,they prevent SCD (which patients dont like he he.)So the fact that she might have been in a lethal rhythm would have caused concern in my book and I, too would have sent her to the ED for a work up. (and i am not even an alarmist, but a lethal rhythm is a lethal rhythm!)

Most are rate related and she could have simply been in afib w/ RVR. If it was VT, she deserves to have the causes ruled out and prevented from happening again. If it was a SVT, the AICD needs to have a higher rate threshold set (maybe 175?), along with a mandatory constant R-R (if she was in afib). They can be set to defib if the rate >then the limit, but after a sustained period of time (like 3 minutes), despite R-R irregularities.

If the device is a pacemaker, too and kicked on b/c of bradycardia, she wouldnt have felt it. Pacemaker joules are much less than those of defibs. Think of how many pts live with their pacemakers contributing to 100% of their rhythm. (They would be saying OUCH every second!) Not all AICDs are pacemakers and vice versa. Is hers both?

I hope this helps...

AICDs are put in to prevent a pt from dying from a lethal rhythm. Period. They dont fix the problem,they prevent SCD (which patients dont like he he.)So the fact that she might have been in a lethal rhythm would have caused concern in my book and I, too would have sent her to the ED for a work up. (and i am not even an alarmist, but a lethal rhythm is a lethal rhythm!)

Most are rate related and she could have simply been in afib w/ RVR. If it was VT, she deserves to have the causes ruled out and prevented from happening again. If it was a SVT, the AICD needs to have a higher rate threshold set (maybe 175?), along with a mandatory constant R-R (if she was in afib). They can be set to defib if the rate >then the limit, but after a sustained period of time (like 3 minutes), despite R-R irregularities.

If the device is a pacemaker, too and kicked on b/c of bradycardia, she wouldnt have felt it. Pacemaker joules are much less than those of defibs. Think of how many pts live with their pacemakers contributing to 100% of their rhythm. (They would be saying OUCH every second!) Not all AICDs are pacemakers and vice versa. Is hers both?

I hope this helps...

I agree that ANY ICD shock needs investigation even if the shock happened in isolation. The pt may potentially require an adjustment of medications or ischemia workup. Also, if the Patient loses conciousness prior to being shocked, the ICD isnt set right or functioning correctly. These things are meant to work before someone goes out.

The ER probably isnt the best place to go however. Most(all) aicd pt's are seen by a specialist/EP doc, and these guys would either prefer the pt to come into the office/lab (to have the device interrogated) or admitted as outpatient for the same reason. ER's are not equipped with the specialized machines(or EP Doc's/techs)) used to interrogate ICD's. However, if the shock is accompanied by distressing symptoms or is recurrent, a visit to ER would be preferable as the shock-inducing rhythm problems may require a lido or cordarone drip ASAP..but again a physician would probably prefer to directly admit to a cardiac unit and bypass all the ER red-tape and delays.

As was mentioned, sometimes fast SVT can trigger a shock (most commonly if pt also has an underlying bundle-branch block), but the newer (and older if 'tweeked' correctly) ICD's can recognize these rhythms and not shock.

And, the pacer/ICD's (which most are anyway) can even 'pace' someone out of a tachy-dysrhythmia rather than resorting to defibrillation.

Regardless, any shock rendered by an ICD needs investigation. Yes perhaps it did it's job and prevented sudden cardiac death, but an unnecesary or potentially avoidable aicd discharge is an awful thing for the pt to experience.

I cant say I would be trying to get an appointment with an EP MD if my pt was shocked, nor as a homecare RN would I be calling the company rep (usually an RN) to see if they could come out and run the history on the AICD. I would send the pt straight to the ED and let them deal with that and any future (or refractory) VT.

We (in the ED) are very accustomed to pts coming in when their AICDs fire and call the company ourselves. Most of the time the rep sees them in the ED and fixes any programming errors. And we replace the magnesium, start the amio drip, etc etc etc...

But thats just my opinion bc I never worked in homecare and would probably feel helpless without the resources I am used to in the hospital.

I agree that ANY ICD shock needs investigation even if the shock happened in isolation. The pt may potentially require an adjustment of medications or ischemia workup. Also, if the Patient loses conciousness prior to being shocked, the ICD isnt set right or functioning correctly. These things are meant to work before someone goes out.

The ER probably isnt the best place to go however. Most(all) aicd pt's are seen by a specialist/EP doc, and these guys would either prefer the pt to come into the office/lab (to have the device interrogated) or admitted as outpatient for the same reason. ER's are not equipped with the specialized machines(or EP Doc's/techs)) used to interrogate ICD's. However, if the shock is accompanied by distressing symptoms or is recurrent, a visit to ER would be preferable as the shock-inducing rhythm problems may require a lido or cordarone drip ASAP..but again a physician would probably prefer to directly admit to a cardiac unit and bypass all the ER red-tape and delays.

As was mentioned, sometimes fast SVT can trigger a shock (most commonly if pt also has an underlying bundle-branch block), but the newer (and older if 'tweeked' correctly) ICD's can recognize these rhythms and not shock.

And, the pacer/ICD's (which most are anyway) can even 'pace' someone out of a tachy-dysrhythmia rather than resorting to defibrillation.

Regardless, any shock rendered by an ICD needs investigation. Yes perhaps it did it's job and prevented sudden cardiac death, but an unnecesary or potentially avoidable aicd discharge is an awful thing for the pt to experience.

I cant say I would be trying to get an appointment with an EP MD if my pt was shocked, nor as a homecare RN would I be calling the company rep (usually an RN) to see if they could come out and run the history on the AICD. I would send the pt straight to the ED and let them deal with that and any future (or refractory) VT.

We (in the ED) are very accustomed to pts coming in when their AICDs fire and call the company ourselves. Most of the time the rep sees them in the ED and fixes any programming errors. And we replace the magnesium, start the amio drip, etc etc etc...

But thats just my opinion bc I never worked in homecare and would probably feel helpless without the resources I am used to in the hospital.

I think you misunderstood me. Obviously, trying to 'make an appointment' at an office would be silly. Perhaps my angle is different than yours because the ep-lab at the hospital where i'm employed is fairly busy and the Docs therein are readily accesible 24/7(by answering service). They prefer to (and do so regularly) directly admit to the cardiac floor and bypass the ED red-tape/delays. (keep in mind we're speaking of an isolated discharge with no precipitating/continuing symptoms or recurrence) Also as mentioned, if the pt is having recurrent shocks or distressing symptoms a trip to the ED is preferable as things may need to get started asap. Unfortunately, definitive treatment cant be given in the ED and these pt's get admitted anyway.

Yes, i agree that a home-health nurse would probably feel helpless in this situation. If i were the home-health nurse and my pt got defibrilated in front of my eyes i'd be on the horn to 911. However, if my pt makes the statement 'i got shocked a few hours ago but i feel ok' a call to the ep-doc would (in my opinion) be the first thing i'd do. If he then says to call 911, it'd be out of her hands.

so they put in a internal defib r/t bouts of v-tack or even bradycardia episodes...okay stands to reason there...this week she complained that it went off...okay i didn't panic..that is what they put them in for right?!?!? so i charted and monitored her closely...all vs were wnl (actually better than a month ago!).... but then it went off another time in the middle of the night...

i am just taking a stab at this but here goes:

when the internal defibs. discharge, aren't they supposed to make a little noise to warn the patient -- "hey, here it comes! get ready". if hers is not giving a warning "beep", then maybe her cardiologist can enable this function so it won't freak her out next time it happens (and btw - i agree with driving home the point that this is exactly what those little gadgets are supposed to do). the shock gives you quite a little kick from what i understand -- it would probably scare anyone, so maybe that is why she panicked (plus it is a new experience for her).

i am sure she was told all of this by the ep doc, cardiologist, nurses, etc... but sometimes people just don't hear it (even when they are shaking their head yes... go figure), so maybe a little more (re)education is called for. also explain about the lifespan of the battery and how it can fluxuate from patient to patient depending on how often they require defibrillation. with all her misfortune, don't want her to be bent out of shape thinking that she got a bad battery that only lasted 5 years when mary's next door has been in 8 years.

stupid question, but i guess she was not on telemetry on your floor -- would have been nice to have been able to see what was going on with her ecg. another question for you (can you tell i'm a student)... what if she had a 6 beat run of pvcs -- that qualifies as vt - right? but yet she might not be that symptomatic. how quickly do the icds defibrillate? if the answer is milliseconds (instantly), then that could be a possibility of why it is discharging without her being symptomatic -- or -- maybe she is symptomatic (sob, diaphoretic), but she attributes that to her long-term brittle iddm rather than her new onset cvd ?????

i just keep hearing the words of one of our cardiologists playing over and over in my head: "if you ever put a magnet over one of my patients again, i will hurt you! that icd is the smartest thing in this room, me included". i am paraphrasing (wasn't in the room) and he is a little dramatic, but it made an impression on me: trust the gadget.

those are just my (simplistic) thoughts . i enjoy reading these types of posts as they get me to thinking "what if" not to mention that i gain lots of valuable info from the posts/responses....so educate me with your replies!

lifelongstudent

what i want to know is, why did u put a magnet on the pm that got him so mad? i am sure it wasnt just for the hell of it!

and i also dont agree with him that the machines are the smartest things in the room-by any means. that is why u treat your pts, not the machines....

s(bleep), people scratching themselves can look like vt if u only watch the monitor!!

=lifelongstudent]so they put in a internal defib r/t bouts of v-tack or even bradycardia episodes...okay stands to reason there...this week she complained that it went off...okay i didn't panic..that is what they put them in for right?!?!? so i charted and monitored her closely...all vs were wnl (actually better than a month ago!).... but then it went off another time in the middle of the night...

i am just taking a stab at this but here goes:

when the internal defibs. discharge, aren't they supposed to make a little noise to warn the patient -- "hey, here it comes! get ready". if hers is not giving a warning "beep", then maybe her cardiologist can enable this function so it won't freak her out next time it happens (and btw - i agree with driving home the point that this is exactly what those little gadgets are supposed to do). the shock gives you quite a little kick from what i understand -- it would probably scare anyone, so maybe that is why she panicked (plus it is a new experience for her).

i am sure she was told all of this by the ep doc, cardiologist, nurses, etc... but sometimes people just don't hear it (even when they are shaking their head yes... go figure), so maybe a little more (re)education is called for. also explain about the lifespan of the battery and how it can fluxuate from patient to patient depending on how often they require defibrillation. with all her misfortune, don't want her to be bent out of shape thinking that she got a bad battery that only lasted 5 years when mary's next door has been in 8 years.

stupid question, but i guess she was not on telemetry on your floor -- would have been nice to have been able to see what was going on with her ecg. another question for you (can you tell i'm a student)... what if she had a 6 beat run of pvcs -- that qualifies as vt - right? but yet she might not be that symptomatic. how quickly do the icds defibrillate? if the answer is milliseconds (instantly), then that could be a possibility of why it is discharging without her being symptomatic -- or -- maybe she is symptomatic (sob, diaphoretic), but she attributes that to her long-term brittle iddm rather than her new onset cvd ?????

i just keep hearing the words of one of our cardiologists playing over and over in my head: "if you ever put a magnet over one of my patients again, i will hurt you! that icd is the smartest thing in this room, me included". i am paraphrasing (wasn't in the room) and he is a little dramatic, but it made an impression on me: trust the gadget.

those are just my (simplistic) thoughts . i enjoy reading these types of posts as they get me to thinking "what if" not to mention that i gain lots of valuable info from the posts/responses....so educate me with your replies!

lifelongstudent

I am impressed that your hospital has empty beds and can take direct admits!! Who knew that happened in the real world??

I think you misunderstood me. Obviously, trying to 'make an appointment' at an office would be silly. Perhaps my angle is different than yours because the ep-lab at the hospital where i'm employed is fairly busy and the Docs therein are readily accesible 24/7(by answering service). They prefer to (and do so regularly) directly admit to the cardiac floor and bypass the ED red-tape/delays. (keep in mind we're speaking of an isolated discharge with no precipitating/continuing symptoms or recurrence) Also as mentioned, if the pt is having recurrent shocks or distressing symptoms a trip to the ED is preferable as things may need to get started asap. Unfortunately, definitive treatment cant be given in the ED and these pt's get admitted anyway.

Yes, i agree that a home-health nurse would probably feel helpless in this situation. If i were the home-health nurse and my pt got defibrilated in front of my eyes i'd be on the horn to 911. However, if my pt makes the statement 'i got shocked a few hours ago but i feel ok' a call to the ep-doc would (in my opinion) be the first thing i'd do. If he then says to call 911, it'd be out of her hands.

Okay, I know this sounds kinda silly...but I can't get this thought out of my head about not panicing about an intenal defib going off...

I put this in General but no responce..so best go with my heart nurses to get a good feel for why I don't panic with these things going off! Should I???

Thanks in advanced...

Here is the post:

So I have this patient...she is in her late 70's and basically a medical train wreck sorry to say...

Brittle diabetic (noncompliant of course despite great efforts), was a canidate for dialysis for about 5 years before they actually chose to put in a shunt (when she went into renal failure...a little to little too late scenero), that shunt infected..so next one took. Then she started going to dialysis and it was working but they only had her go once a week and with that infection that occured and not enough dialysis...well, heart complications...poor thing!

So they put in a internal defib r/t bouts of v-tack or even bradycardia episodes...okay stands to reason there...(electrolytes out of whack...ouchie, K being a large factor).

This week she complained that it went off...okay I didn't panic..that is what they put them in for right?!?!? So I charted and monitored her closely...all vs were wnl (actually better than a month ago!).

But then it went off another time in the middle of the night and the Night Nurse paniced! She called 9-11 and they rushed her to the hospital....

Okay..am I wrong or isn't that why they put the defib in in the first place...to correct arrythmias as they occur??? They are going to go off till things are either corrected (med or surgery) or they just get to keep getting shocked...

I have had patients that have had these things go off a few times a day every day in their lives...so I don't get the reason for the panic!

Well..there was a good thing that occured, the other shunt infected so she is in the hospital to get another one, and deal with the infection...so there is a good point...

...BUT sending a patient in because it went off twice???

Comments appreciated...I don't want to sound like I don't care, but I don't understand this. It is like calling 9-11 because someones heart medications slowed the heart to normal but this is out of norm for the patient...uhggggg!

I am new to the ICCU but when our patients are discharged from the unit with an AICD they are instructed to seek medical assistance if the AICD fires two or more times in a row ......indicating that the patient is have dysrrhythmias...........since the AICD is not the sole treatment ...I would think it is more like a preventive. I think the patient should be seen to check if adjustments in meds or electrolytes, or to examine the patient to remove offending cause of the dysrhythmias............I do not think it is wise to disregard that the patient is having an episode that would require defribrillation ..............I am new but that is my thought on the subject as a newbie ............please correct me if I am wrong..........would like to know