Device Management
PPM, ICD, CRT, and loop recorders — indications, recognition, and triage (not programming).
Learning Objectives
- 1.Identify the cardiac device types and their indications.
- 2.Recognize device-related problems and remote-monitoring concepts.
- 3.Triage device issues within scope and escalate appropriately.
Overview
You’ll follow many device patients. The job is knowing what each device does, recognizing problems (shocks, infection, malfunction), and triaging — interrogation/programming is performed by device specialists.
The devices & indications
- •Permanent pacemaker (PPM): treats symptomatic bradycardia / high-grade AV block.
- •Implantable cardioverter-defibrillator (ICD): prevents sudden cardiac death (e.g., low EF, prior VT/VF).
- •Cardiac resynchronization therapy (CRT): biventricular pacing for selected HFrEF with conduction delay (often wide LBBB).
- •Implantable loop recorder: long-term rhythm monitoring (e.g., unexplained syncope, cryptogenic stroke).
Recognition & monitoring (not programming)
- •Device interrogation (in-office or remote) reads device data — performed by device clinic/specialists.
- •Remote monitoring transmits arrhythmia/device alerts; ensure patients are enrolled and transmitting.
- •You recognize and triage; you don’t reprogram.
Scope
This is conceptual understanding for follow-up, complication recognition, and escalation. APPs do not perform these procedures, program devices beyond recognition/triage, or read raw images — those are the proceduralist’s/imager’s role.
Problems to recognize
- •ICD shocks: a single shock (urgent contact) vs multiple shocks/"shock storm" (emergency).
- •Pocket/lead infection: redness, warmth, drainage, fever.
- •Lead issues: dizziness, syncope, palpitations, hiccups (diaphragmatic stimulation).
- •Peri-op and MRI considerations require device-team coordination.
Escalate
Multiple ICD shocks or device-site infection signs are emergencies; a single shock warrants urgent device-clinic/physician contact.
Common beginner mistakes
- •Treating multiple ICD shocks as routine.
- •Missing a pocket infection.
- •Assuming you can reprogram/adjust a device (out of scope).
- •Not confirming remote-monitoring enrollment.
Nurse / MA workflow connection
- •Nurses triage device/wound and shock calls; MAs document the wound and any shocks and flag them.
Mini cases
An ICD patient reports three shocks in an hour and now feels unwell.
Action?
Show answer
Multiple ICD shocks ("shock storm") with symptoms is an emergency — direct to 911/ED and notify the physician/EP team. Not a routine device-clinic appointment.
A CRT candidate is identified — HFrEF with a wide LBBB despite GDMT.
Why CRT?
Show answer
CRT (biventricular pacing) resynchronizes contraction in selected HFrEF patients with conduction delay (wide LBBB), improving symptoms/outcomes. Refer to cardiology/EP for evaluation.