Implantable cardioverter-defib.

Adapted from the IAEM Clinical Guideline.


  • Circa 2000 people in Ireland have an ICD
  • The commonest reasons for ED presentation are:
  • All EDs should have a cardiac magnet to disable ICDs


  • Follow ACLS guidelines for patients fitted with ICDs
  • Check location of the cardiac magnet in your ED
  • AEDs can be used as normal as per BLS protocols
  • It is safe to touch a patient with an ICD that is firing
  • Defib. pads should not be placed directly over ICD units


Cardiac arrest

  • Treat patient as per ACLS guidelines
  • Consider need to place magnet over ICD until hemodynamically stable
  • When patient’s condition allows, interrogate ICD to determine whether shocks occurred or whether these were appropriate or not

ICD shocks in non-arrested patient

  • Manage as per ACLS guidelines
  • Commence Telemetry monitoring
  • Arrange urgent ICD interrogation to confirm if appropriate or inappropriate shocks have occurred:

Inappropriate Shocks:

  • Place magnet on ICD
  • Cardiology service will re-programme ICD or if due to lead fracture switch ICD off, monitor on telemetry and arrange for ICD revision

Appropriate Shocks:

  • Consider applying magnet to ICD and treat arrhythmia as per ACLS guidelines. (Appropriate shocks may be delivered quicker through the ICD.)
  • Remove magnet when arrhythmia controlled

Arrhythmia / Palpitations / Syncope without shocks

  • Manage ABC as per ACLS guidelines
  • Commence Telemetry monitoring
  • Arrange urgent ICD interrogation to confirm if non-delivery of shocks was appropriate or inappropriate

If evidence of cardiac arrhythmia (SVT or VT) and no ICD shocks

  • Treat arrhythmia as per ACLS recommendations
  • Interrogate ICD to see if the lack of shock was appropriate or inappropriate
  • Consult/admit to Cardiology

If no evidence of arrhythmia and patient complaining of palpitations:

  • Consult Cardiology service for telemetry advice and to arrange follow-up

If no evidence of arrhythmia and patient complaining of syncope:

  • Admit for telemetry ECG monitoring and/or Cardiology follow-up

Non ICD-related presentation:

  • Surgical interventions that may require diathermy - turn off ICD for surgery, keep on telemetry during procedure and switch ICD on afterwards
  • Risk of bacteremia related to trauma or medical / surgical procedure - cover with antibiotics as per peri-procedurally and after trauma for first 6 months after ICD / leads revision
  • Advanced Imaging: MRI can interfere with ICD functioning and in general ICD patients should not undergo MRI. CT imaging, fluoroscopy, nuclear medicine and plain X-ray are not associated with ICD problems
  • Other procedures – obtain Cardiology consultation regarding appropriate management

Pre-hospital care:

  • The clinical management of patients in an ambulance setting (i.e. pre-hospital care) is governed by the PreHospital Emergency Care Council (PHECC) clinical practice guidelines (CPGs) for pre-hospital practitioners. The current CPGs include the management of ICD-related issues in patients requiring cardiac life-support. If there are no ACLS practitioners available for a patient in cardiac arrest, the patient should be managed with normal BLS protocols including the use of an AED

Sudden unexplained death:

  • All sudden unexplained deaths with an implanted ICD should get a mandatory ICD interrogation

Content by Dr Íomhar O' Sullivan . Last review Dr ÍOS 12/07/21.