an 'Atrial Fibrillation' Kinda day.

Two Patients:

50yo F sent in from cardiologist office (routine visit) for AF with RVR @150. Completely asymptomatic. denies any CP, sob, nausea, vomitting, palpitations or other complaints. 

PMHx - recent STEMI 2months ago with drug eluting stent in LCx, on asa and plavix. 

Outcome - Pt given 20mg Diltiazem, no major response. Given another 20mg bolus and started on Diltiazem drip (started at 5mg/hr, got up to 15mg/hr) for HR between 95-110, BP @108/67. Heparin gtt. Still asymptomatic. Trop negative. Seen by cardiologist, Admitted to Telemetry. 

80yo F hx HTN brought in by fire/rescue for witnessed syncope. On arrival to ED found to be in Afib with RVR @130, BP146/77. Asymptomatic. Doesn't remember syncopal episode. denies Hx of Afib or cardiac issues. PERC score 2/8, Wells score for PE - 1.5 = low risk for PE.  

Outcome - 20mg Diltiazem ordered, nurse gave 10mg first, HR decreased to 78, BP @98/57. still asymptomatic. (Labs pending at time of signout). Plan for Admit. 

Teaching Point: Management of A.Fib

Quick Review: For tachyarrythmias always think: 

1. Chant your mantra - IV, O2, Monitor. 

2. Stable or unstable?

3. Pwaves present?

4. Regular or Irregular?

5. Narrow or Wide?

Afib - Narrow, Irregular, both of these patients were stable.

GREAT! Now what do you do?

1. Cardiovert (i.e Rhythm control) 

     - if patient is unstable, SHOCK 'EM. 

     - If patient is stable, <48hrs from onset of new/paroxysmal Afib

       REMemeber to sedate the awake and stable patient.

2. Rate control - CaChannelBlocker or Bblocker or IV Magnesium

-anedoctally alot of EM physicians used Diltiazem as preffered rate controller in AF. Cardiologist

typically used Bblocker. Use whatever floats your Boat!

- Diliazem - ACLS dosing is 20mg bolus over 2mins, if not successful then 25mg bolus, then Diltiazem gtt 5-15mg/hr. 20mg might be much in the little old lady with a BMI of 19. Its ok to Low-ball and then titrate up the bolus. STAND BY THE BEDSIDE. Donot give a 5mg bolus and walk away. Wait for it. Diltiazem is a long acting agent but with a quick onset of action. Try the 2.5mg/min bolusing method. Our 1st patient needed 40mg + a gtt to be rate controlled, The 2nd stayed HR<100 after just 10mg. This is where medicine becomes more art than science.

-Metoprolol 5-15mg IV over 5-15min

-Magnesium IV - 2g over 2mins (Rosens Chpt 78, pg 1233; 6th Edition)

3. Anti-coagulate!

See a pretty good lecture on Tachyarrythmias here