Penetrating The EM provider should assume cardiac injury with any penetrating injury to the chest, neck, axilla, back, or upper abdomen Gunshots cause rapid exsanguination from extensive tissue destruction as a result of the bullet’s kinetic energy Stab wounds are more likely to lead to cardiac tamponade Electrical Electrical injury to the heart can occur from man-made electricity or lightning Death is caused by dysrhythmia, usually VF Because of a prolonged delay in recovery of respiratory drive, prolonged CPR may be indicated in some cases Manage dysrhythmias per PALS algorithm Obtain an EKG when stable If a patient is asymptomatic with a normal EKG, no further cardiac evaluation is warranted EVALUATION OF THE PATIENT WITH A CARDIAC DEVICE Goals of Treatment The focus for the EM provider is to recognize and anticipate device-related malfunctions and complications in patients presenting to the ED CLINICAL PEARLS AND PITFALLS Atrial septal defect occluder devices may, on rare occasions, present with erosion through the heart and hemorrhagic shock Sometimes they erode into the esophagus Initial history should identify pacemaker-dependent patients Patients with a malfunctioning ICD that cannot deliver lifesaving therapy should be admitted to the hospital on telemetry in a unit that can respond rapidly to a lethal rhythm Complications involving pacemakers and ICDs occur more frequently around the time of implant Patients discharged from the hospital with ventricular assist devices (VADs) should have an action plan in place with local Emergency Medical Services as well as the local ED Current Evidence