Rapid A-fib / Pneumonia / Cardizem

[medic112]

You have a pt, mid to late 70's. I cant remember her exact age. Called to a nursing home for trouble breathing, upon entering the room find the pt, sitting up in bed coughing up green / yellow sputum, AOCx4, answering questions appropriately, full sentences with intermittent coughing up the nasty stuff, also has a low grade fever past few days. Staff states her pulse Ox fluctuating between 85-90% they have her of course on the normal 1.5 Lpm NC. Hx of A-Fib / HTN / recurrent pneumonia.

only complaint from pt is mild dyspnea. no other complaints. (-) CP, nausea / vomiting / diarrhea, no recent falls or trauma. took normal meds today. Staff is concerned that she might have pneumonia. Lung sounds diminished Right lower lobe, (-) wheezing / rhonchi / crackles. Pulse Ox is 92% on monitor, Monitor Rapid A-fib rate of 170-210 at times. still no other complaints. On 4 lpm NC pt's O2 sat up to 97 - 98%. Pt denies any complaints of SOB now and that it is easier to breath.

My question is... we need to call command for orders of Cardizem. ETA to hospital was about 10min / 15 at most. Pt was stable. BP was within normal limits. My preceptor, kept asking me if there was anything i wanted to do.. i assumed he ment treating her with the Cardizem. Which i did not do, number one because of the history of a-fib and her being hemodynamically stable.

Later we talked a little bit, he was thinking along the lines of it didnt really matter about hx when the rate is that high, and that if we didnt do cardizem then we shoudl have considered treating her with maybe a fluid bolus - i agreed with that, however by the time we would have done that we were at the hospital, i did jack a lock into her, but didnt hang fluids. and then he said something about possibly a neb (albuterol) tx, which i again disagreed with because of the tachycardia already.

My question on here is,, would you have pushed or considered the Cardizem?

thanks

[crotchitymedic1986]

Tough to say without knowing if she were febrile and if she was orthostatic. Her underlying problem is pneumonia, so the increased heart rate could be from fever/sepsis, poor oxygenation, and/or dehydration. If her temp is above 102, i would say treat the fever and the dyspnea first, treat the AFib if it doesnt respond (in the ER, not the field). If orthostatic, a small fluid bolus wouldnt hurt. As long as her B/P was good, and you had IV access, I wouldnt be too aggressive with the AFIB, especially without knowing the other 50 meds she was on.

[medic112]

my thoughts exactly. The problem being i argued this up and down with my preceptor. I could have given a little fluid bolus. her temp was above 102, and my working diagnosis was sepsis, secondary to pneumonia. the rapid afib was due to her being septic. after she stated that she was feeling better, i didnt feel it nessicary to treat the afib, and the hospital ended up putting her in a non monitored hallway bed, atleast for some time.

Unknown about the orthostatics, we didnt stand her up or anything. but semi-fowlers her bp was within normal limits.

thanks for the input

[Mateo_1387]

First off, thanks for giving a fairly complete clinical picture.

Question for you, if you were 90 miles from the hospital, and without contact with medical control, how would you have treated this patient?

The reason I ask is because a patient who has a heart rate of greater than 170 will become ‘unstable’ if left untreated. I understand that close proximity to the hospital may mean you defer some treatments to them, but for the sake of mental exercise, how would your treatment change with the above scenario?

I think the call to withhold the albuterol was wise with the presence of tachycardia. Did you consider the use of steroids?

Something else to consider, the Rapid Ventricular Response may be due to her underlying infection, but to treat the underlying infection, therapy will have to be given over several weeks. With a ventricular rate of 170 and greater, the patient will not be able to tolerate being left untreated.

[DartmouthDave]

Hello,

I agree with a fluids and see what happens.

As for the Afib. One doesn't know how long she has been in Afib (whatever the rate). If she converts she mat stoke on you and as noted above (for now) she is stable. Like noted above, the pt was stable.

As for the steroids. What is the theory there?

Cheers,

David

[medic112]

im not sure about the steroid treatment myself either, maybe he will be able to enlighten us later in this post.

As for the question to me.. had the pt been unstable and longer transport time. i would have probably tried fluid bolus's first. she is dehyrdated due to the underlying infection.. most likely.. and had that not converted her, yes possibly tried the cardizem.. however i am really hessitant with using that medication on pt's that have a history of afib, simply because as much of us know she could have a clot forming in the atrium that once the rate is slowed down she could throw that and back stuff happens.

[Mateo_1387]

The goal of using diltiazem is to control the ventricular rate, not to convert the rhythm. Normally, electrical cardioversion is used to convert the rhythm. A heart rate of 170 beats per minute or more is dangerous, and will not sustain. At a rate that fast, the subendocardium will be oxygen deprived. Also, at a rapid rate, the oxygen demand of the heart is increased. It will be important for your patient that, say during an hour-long transport, the ventricular rate be controlled. You are also dealing with a patient who has a V/Q mismatch. She has low hemoglobin saturation, which is a late sign of oxygen deprevation. Keep in mind that now your patient's heart is under even more stress to maintain a ventricular rate of 170 and more.

Although conversion of atrial fibrillation may occur with rate controlling drugs, it more than likely will not occur. Most conversion is accomplished through electrical cardioversion. Again, in this case, I think it is important to control the ventricular rate, and anticoagulant therapy can be utilized until conversion can be accomplished days later in the hospital.

The steroid therapy is for inflammation in the lungs. Since you are hesitant on using albuterol, and rightly so, some form of therapy, if available should be used. Steroid therapy may be an option. Consider again, my scenario that you had an hour + long transport, do you think these treatments would be appropriate?

[DartmouthDave]

Hello,

Nice protocols. Rate control, from my experience, (for what it is worth) usually isn't a treatment option for many EMS services. Just cardioversion if the patient is unstable.

In regards to the main body of your post Mateo_1387 I have seen CCB, beta blockers.....ect...used in the ED and ICU to slow things down while anticoagulation is acheived.

However, I can not recall seeing steroids used for pneumonias. Unless, there was a hx of COPD for example. Again, not a bad protcol to have if one has longer transport times.

Medic 112. Did you have a chance to see what happened at the local ED?

Cheers

[jwraider]

If I was running the perfect call (and I'm new too so I probably wouldn't have been) I would have gotten more info from the staff on her cardiac Hx and PNA Hx.

Like what is her usual HR and rhythm?

What has her temperature been?

That is a pretty fast HR especially at her age.

To answer your question I would have treated her if there was a long transport time and just did what you did if there was a short transport time. She did say her SOB got better with more 02 but either her HR or the gunk in her lungs is a problem and one probably should be addressed.

As far as fluids go I think that HR is too high to say it's due to dehydration/sepsis along with her other S/S. Let's say shes real hot to the touch or the staff informs you she has a high temp maybe that changes things but then again thats more info from the staff that could answer your questions.

[medic112]

The goal of using diltiazem is to control the ventricular rate, not to convert the rhythm. Normally, electrical cardioversion is used to convert the rhythm. A heart rate of 170 beats per minute or more is dangerous, and will not sustain. At a rate that fast, the subendocardium will be oxygen deprived. Also, at a rapid rate, the oxygen demand of the heart is increased. It will be important for your patient that, say during an hour-long transport, the ventricular rate be controlled. You are also dealing with a patient who has a V/Q mismatch. She has low hemoglobin saturation, which is a late sign of oxygen deprevation. Keep in mind that now your patient's heart is under even more stress to maintain a ventricular rate of 170 and more.

Although conversion of atrial fibrillation may occur with rate controlling drugs, it more than likely will not occur. Most conversion is accomplished through electrical cardioversion. Again, in this case, I think it is important to control the ventricular rate, and anticoagulant therapy can be utilized until conversion can be accomplished days later in the hospital.

The steroid therapy is for inflammation in the lungs. Since you are hesitant on using albuterol, and rightly so, some form of therapy, if available should be used. Steroid therapy may be an option. Consider again, my scenario that you had an hour + long transport, do you think these treatments would be appropriate?

right, cardizem wont convert A-fib, however it is protocol (under command line) to use cardizem on rapid afib pts. however contraindicated again because of clots in pt's with a hx of afib and its not a new onset. I should have rephrased it better, it wont "convert" but it would control it because its a calcium channel blocker.

As for the steriod therapy. what does your system use? we have solu-medrol in our system. just curious as to what you use.

To answer jwraiders question, the pt's history was pretty much like i stated in the first post. And her nomal vitals were unknown. i asked and got the normal reply of "well i dont know how she's been the past few days, i just came back to work from being off awhile, and its not really my pt, her's the paperwork. Which wasnt to much help. She did have a temp for the past few days, however it wasnt documented in her chart about any recent VS's. And i did believe she was dehydrated, mild tenting was noted which i did not mention earlier.

Dartmouthdave: yes i have seen CCB used in the field and also in the ED's. I have administered Cardizem once before, when i was a student to an elderly pt, new onset afib (or it wasnt documented) either way. rapid afib, no real complaints, i think Chest pressure with exertion and SOB. EKG rapid afib, called command and got orders for 10 of cardizem gave it slow and in incriments and was able to control her rate prior to arriving in the ED. (little bit longer transport time for her).