ED evaluation and management of implantable cardiac defibrillator electrical shocks

Published:February 29, 2016DOI:


      Patients with implantable cardiac defibrillators not infrequently present to the emergency department after experiencing an implantable cardiac defibrillator shock. This review considers the management of such patients in the emergency department, including appropriate, inappropriate, and phantom shocks as well as electrical storm.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Braunschweig F.
        • Boriani G.
        • Bauer A.
        • et al.
        Management of patients receiving implantable cardiac defibrillator shocks: recommendations for acute and long-term patient management.
        Europace. 2010; 12: 1673-1690
        • Liu C.
        • Ho Y.
        • Lin Y.
        • et al.
        Management of patients with implantable cardioverter defibrillators at emergency departments.
        Emerg Med J. 2007; 24: 106-109
        • Stevenson W.G.
        • Chaitman B.R.
        • Ellenbogen K.A.
        • et al.
        Clinical assessment and management of patients with implanted cardioverter-defibrillators presenting to nonelectrophysiologists.
        Circulation. 2004; 110: 3866-3869
        • Clemo H.F.
        • Ellenbogen K.A.
        My defibrillator fired: what to do?.
        Am Coll Cardiol Curr J Rev. 2001; 10: 76-81
        • Tracy C.M.
        • Epstein A.E.
        • Darbar D.
        • et al.
        2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2012; 60: 1297-1313
        • Devine A.S.
        • Huecker M.
        • Cunningham T.
        • et al.
        Hardware for the heart: the increasing impact of pacemakers, ICDs, and LVADs.
        Emerg Med. 2014; 46 (Available at): 56-75
        • Schaumann A.
        • von zur Mühlen F.
        • Herse B.
        • et al.
        Empirical versus tested antitachycardia pacing in implantable cardioverter defibrillators: a prospective study including 200 patients.
        Circulation. 1998; 97: 66-74
        • Wathen M.S.
        • Sweeney M.O.
        • DeGroot P.J.
        • et al.
        Shock reduction using antitachycardia pacing for spontaneous rapid ventricular tachycardia in patients with coronary artery disease.
        Circulation. 2001; 104: 796-801
        • Auricchio A.
        • Schloss E.J.
        • Kurita T.
        • et al.
        Low inappropriate shock rates in patients with single- and dual/triple-chamber implantable cardioverter-defibrillators using a novel suite of detection algorithms: PainFree SST trial primary results.
        Heart Rhythm. 2015; 12: 926-936
        • Bhavnani S.P.
        • Giedrimiene D.
        • Coleman C.I.
        • et al.
        The healthcare utilization and cost of treating patients experiencing inappropriate implantable cardioverter defibrillator shocks: a propensity score study.
        Pacing Clin Electrophysiol. 2014; 37: 1315-1323
        • Wathen M.S.
        • DeGroot P.J.
        • Sweeney M.O.
        • et al.
        Prospective randomized multicenter trial of empirical antitachycardia pacing versus shocks for spontaneous rapid ventricular tachycardia in patients with implantable cardiac defibrillators: pacing fast ventricular tachycardia reduces shock therapies (pain-free Rx II) trial results.
        Circulation. 2004; 110: 2591-2596
        • Klein R.C.
        • Raitt M.H.
        • Wilkoff B.L.
        • et al.
        Analysis of implantable cardioverter defibrillator therapy in the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial.
        J Cardiovasc Electrophysiol. 2003; 14: 940-948
        • Dichtl W.
        • Wolber T.
        • Paoli U.
        • et al.
        Appropriate therapy but not inappropriate shocks predict survival in implantable cardioverter defibrillator patients.
        Clin Cardiol. 2011; 34: 433-436
        • Credner S.C.
        • Klingenheben T.
        • Mauss O.
        • et al.
        Electrical storm in patients with transvenous implantable cardiac defibrillators: incidence, management, and prognostic implications.
        J Am Coll Cardiol. 1998; 32: 1909-1915
        • Epstein A.E.
        • Baessler C.A.
        • Curtis A.B.
        • et al.
        Addendum to "Personal and public safety issues related to dysrhythmias that may affect consciousness: implications for regulation and physician recommendations: a medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology": public safety issues in patients with implantable defibrillators: a scientific statement from the American Heart Association and the Heart Rhythm Society.
        Circulation. 2007; 115: 1170-1176
        • Thijssen J.
        • Borleffs C.J.
        • van Rees J.B.
        • et al.
        Driving restrictions after implantable cardioverter defibrillator implantation: an evidence-based approach.
        Eur Heart J. 2011; 32: 2678-2687
        • Germano J.J.
        • Reynolds M.
        • Essebag V.
        • Josephson M.E.
        Frequency and causes of implantable cardiac defibrillator therapies: is device therapy proarrhythmic?.
        Am J Cardiol. 2006; 97: 1255-1261
        • Van Rees J.B.
        • Borleffs C.J.
        • de Bie M.K.
        • et al.
        Inappropriate implantable cardiac defibrillator shocks: incidence, predictors, and impact on mortality.
        J Am Coll Cardiol. 2011; 57: 556-562
        • Daubert J.P.
        • Zareba W.
        • Cannom D.S.
        • et al.
        Inappropriate implantable cardiac defibrillator shocks in MADIT II: frequency, mechanisms, predictors, and survival impact.
        J Am Coll Cardiol. 2008; 51: 1357-1355
        • Poole J.E.
        • Johnson G.W.
        • Hellkamp A.S.
        • et al.
        Prognostic importance of defibrillator shocks in patients with heart failure.
        N Engl J Med. 2008; 359: 1009-1017
        • Saxon L.A.
        • Hayes D.L.
        • Gilliam F.R.
        • et al.
        Long-term outcome after ICD and CRT implantation and influence of remote device follow-up: the ALTITUDE survival study.
        Circulation. 2010; 122: 2359-2367
        • Atwater B.D.
        • Daubert J.P.
        Implantable cardioverter defibrillators: risks accompany the life-saving benefits.
        Heart. 2012; 98: 764-772
        • Sweeney M.O.
        • Sherfesee L.
        • DeGroot P.J.
        • et al.
        Differences in effects of electrical therapy type for ventricular dysrhythmias on mortality in implantable cardiac defibrillator patients.
        Heart Rhythm. 2010; 7: 353-360
        • Mishkin J.D.
        • Saxonhouse S.J.
        • Woo G.W.
        • et al.
        Appropriate evaluation and treatment of heart failure patients after implantable cardiac defibrillator discharge: time to go beyond the initial shock.
        J Am Coll Cardiol. 2009; 54: 1993-2000
        • Pacifico A.
        • Ferlic L.L.
        • Cedillo-Salazar F.R.
        • et al.
        Shocks as predictors of survival in patients with implantable cardiac defibrillators.
        J Am Coll Cardiol. 1999; 34: 204-210
        • Moss A.J.
        • Greenberg H.
        • Case R.B.
        • et al.
        Long-term Clinical course of patients after termination of ventricular tachydysrhythmia by an implanted defibrillator.
        Circulation. 2004; 110: 3760-3765
        • McMullan J.
        • Valento M.
        • Attari M.
        • Venkat A.
        Care of the pacemaker/implantable cardioverter defibrillator patient in the ED.
        Am J Emerg Med. 2007; 25: 812-822
        • Sullivan MG
        What to do when a pacemaker delivers repeated shocks.
        in: ACEP News. 2008 (Available at—Practice-Management/What-to-Do-When-a-Pacemaker-Delivers-Repeated-Shocks/)
        • Jacobs I.
        • Sunde K.
        • Deakin C.D.
        • et al.
        International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations: part 6: defibrillation.
        Circulation. 2010; 2010: 325-337
        • Pacifico A.
        • Hohnloser S.H.
        • Williams J.H.
        • et al.
        Prevention of implantable-defibrillator shocks by treatment with sotalol.
        N Engl J Med. 1999; 340: 1855-1862
        • Dorian P.
        • Al-Khalidi H.R.
        • Hohnloser S.H.
        • et al.
        Azimilide reduces emergency department visits and hospitalizations in patients with an implantable cardiac defibrillator in a placebo-controlled clinical trial.
        J Am Coll Cardiol. 2008; 52: 1076-1083
        • Connolly S.J.
        • Dorian P.
        • Roberts R.S.
        • et al.
        Comparison of beta-blockers, amiodarone plus beta-blockers, or sotalol for prevention of shocks from implantable cardioverter defibrillators: the OPTIC study, a randomized trial.
        JAMA. 2006; 295: 165-171
        • Eifling M.
        • Razavi M.
        • Massumi A.
        The evaluation and management of electrical storm.
        Texas Heart Inst J. 2011; 38: 111-121
        • Gatzoulis K.A.
        • Andrikopoulos G.K.
        • Apostolopoulos T.
        • et al.
        Electrical storm is an independent predictor of adverse long-term outcome in the era of implantable defibrillator therapy.
        Europace. 2005; 7: 184-192
        • Wilkoff B.L.
        • Love C.J.
        • Byrd C.L.
        • et al.
        Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management.
        Heart Rhythm. 2009; 6: 1085-1104
        • Brigadeau F.
        • Kouakam C.
        • Klug D.
        • et al.
        Clinical predictors and prognostic significance of electrical storm in patients with implantable cardioverter defibrillators.
        Eur Heart J. 2006; 27: 700-707
        • Greene M.
        • Newman D.
        • Geist M.
        • et al.
        Is electrical storm in ICD patients the sign of a dying heart? Outcome of patients with clusters of ventricular tachydysrhythmias.
        Europace. 2000; 2: 263-269
        • Villacastin J.
        • Almendral J.
        • Arenal A.
        • et al.
        Incidence and clinical significance of multiple consecutive, appropriate, high-energy discharges in patients with implanted cardioverter-defibrillators.
        Circulation. 1996; 93: 753-762
        • Exner D.V.
        • Pinski S.L.
        • Wyse D.G.
        • et al.
        Electrical storm presages nonsudden death: the Antiarrhythmics Versus Implantable Defibrillators (AVID) trial.
        Circulation. 2001; 103: 2066-2071
        • Verma A.
        • Kilicaslan F.
        • Marrouche N.F.
        • et al.
        Prevalence, predictors, and mortality significance of the causative dysrhythmia in patients with electrical storm.
        J Cardiovasc Electrophysiol. 2004; 15: 1265-1270
        • Aliot E.M.
        • Stevenson W.G.
        • Almendral-Garrote J.M.
        • et al.
        EHRA/HRS expert consensus on catheter ablation of ventricular dysrhythmias.
        Europace. 2009; 11: 771-817
        • Zipes D.P.
        • Camm A.J.
        • Borggrefe M.
        • et al.
        ACC/AHA/ESC 2006 Guidelines for management of patients with ventricular dysrhythmias and the prevention of sudden cardiac death.
        Circulation. 2006; 114: 385-484
        • Ritchie J.V.
        • Juliano M.L.
        • Thurman R.
        ECG abnormalities.
        in: Knoop K.J. Stack L.B. Storrow A.B. Thurman R. The atlas of emergency medicine. 3 ed. McGraw-Hill, New York, NY2010
        • Van Herendael H.
        • Dorian P.
        Amiodarone for the treatment and prevention of ventricular fibrillation and ventricular tachycardia.
        Vasc Health Risk Manag. 2010; 6: 465-472
        • Jacob S.
        • Panaich S.S.
        • Zalawadiya S.K.
        • et al.
        Phantom shocks unmasked: clinical data and proposed mechanism of memory reactivation of past traumatic shocks in patients with implantable cardioverter defibrillators.
        J Interv Card Electrophysiol. 2012; 34: 205-213
        • Epstein A.E.
        • Miles W.M.
        • Benditt D.G.
        • et al.
        Personal and public safety issues related to dysrhythmias that may affect consciousness: implications for regulation and physician recommendations: a medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology.
        Circulation. 1996; 94: 1147-1166
        • Epstein A.E.
        • DiMarco J.P.
        • Ellenbogen K.A.
        • et al.
        ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices).
        Circulation. 2008; 117: 350-408