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Skating on Thin Ice

hearttransplant

Philadelphia Fire Department Paramedic Ken Lee was playing goalie during an ice hockey game on June 9, 2004 when an opposing player collided into him, causing him to lose his balance and fall on the ice hard enough to leave a mark on his mask. Within hours, Lee was in the critical care unit (CCU) at the Hospital of the University of Pennsylvania (HUP) -- attached to a machine to assist his heart and on the list to receive a transplant.

When Lee fell, fellow player and paramedic Mark DeFilippo, skated over to help. Lee couldn't move his legs, and DeFilippo immediately assumed Lee had a C-spine injury and took appropriate action. Lee says that had he been the paramedic responding to this call, he might not have done an ECG, but fortunately DeFilippo did.„When the ambulance arrived, the crew wanted to transport Lee to the local community hospital, but DeFilippo insisted that the patient be flown to HUP, where DeFilippo worked as an emergency department (ED) paramedic.

The next thing Lee remembers was being taken from the helicopter to the ED. He still couldn't move his legs and was complaining very loudly, which was out of character for him, about shoulder pain. The X-rays didn't show any spinal damage (and Lee wouldn't remember anything for the next 10 days).

Physicians discovered that Lee had an 11% ejection fraction, which had led to profound hypoxia and the lower extremity paralysis. In addition, he had a viral infection of the heart, which led to a massive myocardial infarction. Surgeons completed a coronary artery bypass graft, but it wasn't effective and Lee was placed on the heart transplant list.

The first thing Lee remembers was someone walking into his CCU room and telling him, "I have good news. We found you a heart."

He quickly responded, "You have the wrong room." But they did have the right room, and Lee received a heart transplant on June 26 -- just 17 days after the incident.

He experienced some complications, including an infection of his sternum, but returned to work eight months later. He continued to work as a paramedic for 15 months before transferring from the fire department to the City of„Philadelphia Medical Examiner's Office.

Heart Transplant Patients

Dr. Christian Barnaard performed the first successful human heart transplant in„South Africa in 1967. Today, tens of thousands of Americans have received heart transplants, and more than 93,000 are waiting for organs -- 2,817 of them await a heart and 145 await both a heart and lungs. Approximately 2,000 heart transplants are performed each year in the„U.S.; less than 50 heart-and-lung transplants are performed.

The one-year survival rate for heart transplant patients is 85%, and the five-year rate is more than 65%. The vast majority of morbidity and mortality for post-transplant patients is infection because the anti-rejection medications that keep the patient's immune system from rejecting the new organ also depress the ability to fight infections.

The„EMS provider needs to understand the differences between a patient with a transplanted heart and the rest of the population to provide better care to the heart transplant patient. Signs and symptoms of a heart attack in a transplant patient could be very different than in a non-heart-transplant patient. A transplanted heart isn't innervated, so the heart transplant patient is„not likely to have chest pain.

A heart transplant patient's sympathetic nervous system can't increase the heart rate based on an increased demand for oxygen, such as when walking up a flight of stairs. Because the transplanted heart isn't innervated, the primary controls for the heart rate aren't used. Atropine will be ineffective at increasing heart rate.

When Lee plays ice hockey now, he exercises on a stationary bicycle for a few minutes first so that his heart is ready for the increased demand. The age and condition of the heart transplant patient will have an effect on how well the patient's heart will respond to changes in oxygen demand.

Care & Treatment

ED visits for heart transplant patients tend to fall into one of three categories: rejection, infection and renal dysfunction.

Rejection:The average heart transplant patient has one to two rejection episodes a year. Most are minor and treated by adjusting the patient's level of medications. After immediate post-surgical care, heart transplant patients go on long-term, anti-rejection medication regimes, normally cyclosporine (an immunosuppressant), azathioprine (which alters antibody production) and prednisone (a steroid).

Infection:The most common infection in heart transplant patients is bacterial followed by viral, then fungal.

Renal Dysfunction:Cyclosporine can be toxic to the kidneys. For this reason, the patient's dosage is closely monitored. In the acute setting, this nephrotoxicity can lead to fluid overload, in turn increasing the heart's pre-load and after-load, leading to congestive heart failure.

Prior to ED arrival,„EMS providers should approach a heart transplant patient the same way they would with any other patient. Ensure the scene is safe, take body substance isolation (BSI) precautions, assess the patient's level of consciousness and assess the ABC's (with C-spine precautions as indicated). Treat any life-threatening findings as you go. Once the„EMS provider becomes aware that the patient is a heart transplant patient, they should place the patient on a cardiac monitor and perform a 12-lead ECG. For these patients, native P waves may be present and non-conducting in addition to conducting P waves from the transplanted heart. This can lead to a confusing looking ECG. Because some heart transplants aren't able to transplant the SA node, the patient may have a pacemaker.

Blood pressure and temperature can be important indicators of the heart transplant patient's condition. A high blood pressure may be indicative of renal dysfunction. A fever may be a sign of rejection or infection. In the event of hypovolemia, be cautious in providing IV fluid boluses to the patient. As with any immunocompromised patient, be extremely vigilant to use an aseptic technique when initiating an IV on a heart transplant patient.

Pediatrics

An 18-day-old neonate was the first pediatric patient to receive a heart transplant in 1968, but only lived for five hours. Pediatric patients make up approximately 10% of all heart transplants performed each year. The four main reasons for pediatric heart transplants are malformations of the heart, cardiac tumors, infections and toxins.

Most pediatric heart transplant patients suffered from idiopathic cardiomyopothy, whereas congenital heart problems are very rarely treated with heart transplants, says Charles Murphy, MD, board certified in pediatrics and in pediatric emergency medicine.

In addition to the same concerns for rejection, infection and renal issues, pediatric heart transplant patients face some other challenges and their parents are told to bring the child to the emergency department any time they get a fever.

Pediatric hearts don't become available as often as adult hearts, and a pediatric heart transplant patient commonly will receive a heart that's smaller than the one it's replacing. The pediatric patient's transplanted heart will continue to grow with the patient, and these patients generally do very well.

The issues in treating a pediatric heart transplant patient in the prehospital setting are the same as those in an adult heart transplant patient, such as being judicious when administering fluids. In the ED, these patients are treated with vasopressors earlier than regular pediatric patients. The prehospital provider may find it helpful to contact o-line medical command early in these cases.

John Wildermann, MBA, NREMT-P is the lead operations supervisor with Cetronia Ambulance Corps in„Allentown,„Penn. and has been involved in„EMS for 17 years. He also serves as an Army reserve captain. He can be contacted at„John_Wildermann@hotmail.com.

Ken Lee, NREMT-P can be contacted at„KJLNREMTP@aol.com.

References:

  1. United Network for Organ Sharing.„www.unos.org/data/default.asp
  2. The Organ Procurement and Transplantation Network.„www.optn.org/latestData/rptData.asp
  3. eMedicine.„http://www.emedicine.com/emerg/topic786.htm
  4. American Journal of Critical Care.„http://ajcc.aacnjournals.org/
  5. eMedicine.„http://www.emedicine.com/emerg/topic786.htm
  6. eMedicine.„www.emedicine.com/ped/topic2797.htm

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