A 70-year-old male with past medical history significant for hypertension, hyperlipidemia, coronary artery disease, and congestive heart failure s/p left ventricular assist device on Coumadin is brought in by EMS after he had a witnessed syncopal event by his wife. Patient is now awake and alert and has no complaints. Vitals are as follows: T- 98.6 F; HR- 170; RR- 16; BP- unmeasurable; SpO2- 100% on RA. Patient has a following EKG: 

A patient has a MAP of 45. What is the next best step? 

A. Start CPR

B. Sedate and Defibrillate 

C. Start Dopamine

D. Give Amiodarone 

B Sedate and Defibrillate. Patients with a LVAD do not have palpable peripheral pulses. To obtain a MAP, patient should have a manual blood pressure cuff attached to the patient’s arm, inflate to >120 mm Hg, then deflate with Doppler US over the brachial artery. The pressure reading at which the flow becomes audible is equivalent to the MAP. A normal MAP is 60-90 mm Hg. This patient had a MAP of 45 and therefore unstable Vfib. Patient should be sedated and defibrillated. 

References: 

Helmon, Anton. “LVAD Patients: What You Need to Know.” July 24, 2015. http://www.emdocs.net/lvad-patients-what-you-need-to-know/10/18/19

Bowles CT, Hards R, Wrightson N, et al. Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices. Emergency Medicine Journal 2017;34:842-850. <https://emj.bmj.com/content/34/12/842>. 10/18/19