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CPR for Mechanical Circulatory Support

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7 Î Waveform capnography, which measures and displays the partial pressure of end-tidal carbon dioxide (PETCO 2 ) in exhaled air, can be used to track perfusion in patients in whom more common physical findings used to assess perfusion are not reliable. • A PETCO 2 value of <20 mm Hg in an unresponsive, correctly intubated, pulseless patient with an LVAD would seem to be a reasonable indicator of poor systemic perfusion and should prompt rescuers to initiate chest compressions. Î Peripheral pulse oximetry within normal limits is likely believable, but a low oximetry reading may not represent true hypoxemia because of the diminished pulsations seen in patients with an LVAD. Î The likelihood of a favorable outcome after cardiac arrest increases substantially if the event is witnessed, the event occurs in a public place, bystanders call 9-1-1 and initiate chest compressions promptly, the initial rhythm is VF, an automated external defibrillator is applied and used, and there is a prompt EMS response. • Therefore, it is the consensus recommendation that if an LVAD is definitively confirmed by a trained person and there are no signs of life, bystander CPR, including chest compressions, should be recommended by emergency medical dispatchers for cardiac arrest situations. • However, if mental status, breathing, skin color and temperature, and capillary refill are adequate, a pulseless patient with an LVAD may be in an unconventional, unique physiological state of hemodynamically stable pulseless electric activity (PEA), which we refer to in this population as pseudo-PEA. • Figure 7 illustrates the approach to such a patient. Definitive Evaluation And Care Î As soon as the expertise is available, two primary questions pertain: Are the clinical symptoms attributable to an acute deterioration of native cardiac function or LVAD malfunctioning? • Assessment of inferior vena cava diameter, and its change during inspiration, will provide an estimate of central venous pressure. • Echocardiography can assess downward trends in right-sided heart function. • Valve dysfunction can cause suboptimal LVAD performance. • Impaired LVAD performance can be detected echocardiographically by noting an enlarged le ventricular end-diastolic internal dimension (LVIDd) compared with previous values obtained when the patient was stable.

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