have a representative from the pacemaker manufacturer download the device information if a cardiologist is not available to interpret that information and guide therapy Pacemaker infections are usually seen within weeks of implant and may involve a stitch, the pacemaker pocket, or the entire pacing system Presenting symptoms are similar to that of local wound infection or endocarditis Blood cultures, EKG, and echocardiogram should be obtained Consultation with the implanting physician for management is recommended Noncapture may be a risk of an infected pacemaker and the ED physician should be prepared to give rate support Infections as well as some medications may lead to high pacing thresholds Implantable Cardioverter–Defibrillator Devices ICDs are implanted to rescue the patient from potentially fatal ventricular arrhythmias by delivering high-energy shocks to the heart They also function as pacemakers Devices may be implanted for primary prevention (high-risk conditions before symptoms develop) or secondary prevention (after aborted SCD) Malfunction of the ICD leaves the patient vulnerable to SCD Just as with pacemakers, ICD malfunction may be due to lead or battery failure and/or over or under sensing of the rhythm Patients may receive appropriate or inappropriate shocks The patient may even experience a phantom shock (the perception of a shock in the absence of a discharge from the device) This may be discerned by accessing information recorded by the device In addition, inadequate energy delivery to convert the rhythm to sinus rhythm can be a serious malfunction Evaluation of an ICD should include a history of the event and the underlying condition/reason for implantation Testing may include EKG, two-view CXR, device interrogation, and electrophysiology consultation Representatives from the device manufacturers are available to download information from the devices and can provide relevant information about safety and function recalls on the device A cardiologist trained in the management of ICDs should be consulted Malfunctions that cannot be reprogrammed for proper function in the ED should be admitted for telemetry monitoring and definitive plans for correction If the device delivered a shock appropriately, consult cardiology for further management Ventricular Assist Devices