All EDs should have a cardiac magnet to disable ICDs
Summary
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
Clinical
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 NCHD.ie 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