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Implanteerbare defibrillator

IMPLANTEERBARE DEFIBRILLATOR PROBLEMEN

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1. Kliniek

- defibrillator gaat af
- hoeveel schokken
- sliep patient? Fantoomshocks?
- hartstilstand
- symptomen voor of na de shock
- asymptomatisch
- symptomatisch: syncopale neiging, duizeligheid of ijl hoofd, dyspnee, palpitaties, zweten, retrosternale pijn.
- verschillende situaties zijn mogelijk
- voor of na de shock geen symptomen: defibrillator gaat onnodig af, ofwel omdat atriumfibrillatie geinterpreteerd wordt als ventrikelfibrillatie; ofwel, indien een pacemaker en defibrillator gekoppeld zijn, pacing wordt 'verkeerd begrepen'.  De T-golf wordt begrepen als ventriculaire contractie.  Ofwel is de defibrillator niet echt afgegaan.  Dit kan bij een combinatie pacemaker - defibrillator. De pacing geeft dafragmacontractie wat aanvoelt als shock.  Ook kunnen leidingen gebroken zijn wat een shockgevoel geeft;  Verder is er ook de mogelijkheid van een fantoomshock.  De patient ervaart de shock van het wakker worden als een defibrillatorontlading.
- voor de shock is de patient slecht.  Na de shock is deze beter.  Dit is meestal een goede reactie op een ritmestoornis, meestal op AMI maar soms ook op antiarrhytmica of elecrolietenstoornissen.
- voor de shock is de patient slecht.  Nadien ook nog.  Dit is vermoedelijk een myocardischaemie  (instabiele angor, AMI of congestief hartfalen.)
- Infectie thv de implantatieplaats
- vaak 2 - 6 weken na implantatie
- infectiebeeld: warm, rood, pijn, fluctuaties, koorts, huiderosie
- welke kiemen: snel na implantatie soms Staphylococcus Aureus (agressief beeld), later na implantatie staphylococcus epidermidis. (langzamer beeld). Minder frequent ziet men Escherichia Coli, psudomonas species, streptococcen
- vasculaire problemen:
- oedeem arm aan zijde van implantatie
- superior vena cava syndroom (zelden)
- longembolen: pleuritisbeeld, tachypnee, tachycardie

- psychogeen: fantomschockx (wakker schrikken).  Aanpassingsproblemen (paniekaanvallen), mejeure depressie

 

2. Diagnostiek

- anamnese
- ECG: tijdelijk St-veranderingen na shock.  Dezbetekenen niet altijd ischaemie
- Labo: CBC, electrolieten, CRP, hemoculturen, hartenzymes
- beeldvorming: RX-thorax, bij vermoeden thrombose duplex van venen arm en een angiogram van de longen.

- geen aspiratie van fluctuerende pocket.  Rond implantaat

 

 

Eerste opvang

- CPR - ALS
- vermijd externe defibrillatie in de buurt van de interne defibrillator
- zet zo nodig de defibrillator uit (magneet over plaatsen)
- vraag patient of familie naar de handleiding van de defibrillator

 

Spoeddienst

- vraag consult cardioloog
- monitor patient continu
- behandel ischaemie
- behandel ritmestoornissen
- behandel electrolietenstoornissen
- behandel infectie:
- Cefazolin 1gr IV 3dd
- Vancomycine 1gr IV 2dd
- Cefalexine 500mg PO
- vermijd MRI absoluut
- vermijd electrocoagulatie zo veel mogelijk
 
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