1. IMPANTABLE CARDIOVERTER DEFIBRILLATORS (ICDs) Janet McComb Freeman Hospital Newcastle upon Tyne

2. “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847.

3. rapid access “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847.

4. Eisenberg & Mengert, NEJM, 2001;344:1304-1313 Survival to leave hospital after out of hospital cardiac arrest: effect of arrest being witnessed 41% not witnessed

5. rapid access rapid CPR “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847.

6. Rea et al, Circulation, 2001;104:2413-2516. Survival after out of hospital arrest: effect of early CPR OR 1.41 [1.19-1.66] OR 2.15 [1.85-2.50]

7. Holmberg et al Eur Heart J 2001;22:511-519 Survival after out of hospital arrest: effect of quality of CPR

8. Eisenberg & Mengert, NEJM, 2001;344:1304-1313 Survival to leave hospital after out of hospital cardiac arrest: initial rhythm not witnessed witnessed

9. rapid access rapid CPR rapid defibrillation “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847.

10. Rapid defibrillation Larsen et al Ann Emerg Med 1993;22:80-84

12. Eisenberg & Mengert, NEJM, 2001;344:1304-1313 Survival to leave hospital after out of hospital witnessed cardiac arrest due to VF: PAD

13. Capucci et al Circulation 2002;106:1065-1070 Impact of first responder volunteers p=0.05

14. Myerburg et al Circulation 2002;106:1058-1064 Survival to leave hospital after out of hospital witnessed VF: Impact of AEDs in police cars

15. Survival to leave hospital after out of hospital witnessed VF: Impact of PAD & AEDs in police cars

16. Page et al N Engl J Med 2000;343:1210 VF in 14 of 99 who had lost consciousness (and had an ECG recorded) 6 (40%) survived to leave hospital Eisenberg & Mengert, NEJM, 2001;344:1304 home 71% nursing home 8% public place 21%

17. Survival to leave hospital after cardiac arrest

18. rapid access rapid CPR rapid defibrillation “Chain of Survival” Cummins et al Circulation 1991;83:1832-1847.

20. 11 seconds

21. one or more leads, which will sense the heart rhythm pace the heart defibrillate the heart a generator, which contains the electrical circuitry for this The ICD comprises

22. RA lead LV lead RV leads

27. u 62 cc u Dual-chamber u 35-Joule output u Active Can ® electrode

28. Mortality reduction in ICD trials Primary preventionSecondary prevention

29. Myerberg et al Am J Cardiol 1997;80:10F-19F 1010 2020

30. Emergencies in ICD patients Shocks Rhythm problems Cardiac problems Other emergencies

31. Emergencies in ICD patients: Other emergencies Treat as usual

32. Emergencies in ICD patients: Cardiac problems Heart failure is common, treat as usual Myocardial infarction occurs, treat as usual (ECG may be paced, making it more difficult to interpret)

33. Emergencies in ICD patients: Shocks Shocks may be appropriate, or inappropriate

35. Emergencies in ICD patients: Shocks Appropriate shocks VT or VF

36. Emergencies in ICD patients: Shocks Inappropriate shocks AF sinus tachycardia lead fracture lead displacement sensing problems

37. Double counting: sensing from RV & LV

38. Double counting: LV lead displacement

39. Emergencies in ICD patients: Shocks Patients having one or two shocks are advised to contact their ICD clinic within 24 hours if they feel well

40. Emergencies in ICD patients: Shocks Patients having multiple shocks are advised to contact their nearest CCU or 999

41. Emergencies in ICD patients: Shocks Monitoring & recording of rhythm is important (appropriate vs inappropriate) If the shocks are inappropriate the ICD can be disabled by placing a magnet over it

42. Emergencies in ICD patients: Shocks Inappropriate shocks AF sinus tachycardia lead fracture lead displacement sensing problems drugs programming /revision

44. Emergencies in ICD patients: Rhythm problems “the ICD isn’t working” treat rhythm problem as usual

45. Emergencies in ICD patients: Cardiac arrest “the ICD isn’t working” If the ICD doesn’t deliver a shock within 20 - 30 seconds, treat as usual If the ICD shocks, but does not resuscitate, treat as usual

47. ICDs: conclusions Many of the patients you resuscitate should receive an ICD Many of the patients you thrombolyse should be assessed for an ICD

48. ICDs: conclusions Patients with ICDs should be treated in the usual way If the ICD does not appear to be working treat cardiac arrest in the usual way If the ICD is giving “inappropriate” shocks it can be disabled with a magnet

49. ICDs: conclusions The ICD will not hurt bystanders or those resuscitating a patient So, don’t be concerned, and treat the patient as normal!

50. BRUGADA SYNDROME, LONG QT LEFT VENTRICULAR FUNCTION? RESUSCITATION FROM VT or VF REVASCULARISATION + RISK FACTOR MODIFICATION, ASA,  BLOCKERS, STATINS, etc NORMAL ACUTE ISCHAEMIA? CORONARY ARTERY DISEASE? RVOT TACHYCARDIA, FASCICULAR TACHYCARDIA, PRE EXCITED AF, CONSIDER ICD NYHA IV ACE I, SPIRONOLACTONE,  BLOCKERS, DIGOXIN NYHA I-III AMIODARONE REVASCULARISATION + RISK FACTOR MODIFICATION, ASA,  BLOCKERS, STATINS, etc ACUTE ISCHAEMIA? CORONARY ARTERY DISEASE? ACE I, SPIRONOLACTONE,  BLOCKERS, DIGOXIN IMPAIRED CONSIDER ICD EP REFERRAL