Rapid A-fib / Pneumonia / Cardizem

[Niftymedi911]

I'm gonna have to stand with Mateo on this one. Going wayyyyyyy back to your first ACLS class... What did your instructor tell you?? Anyone? A heart cannot perform at its best when its beating 3x faster then its desgined to. With someone already having a compromised cardiac function, its only a matter of time before (even in sepsis) hypotension and failure will start to set in. I agree it ultimately sounds like the patient's is suffering from ARDS secondary to Pneumonia with a mix of sepsis. However, it all depends on how long the patient's been in that rhythm. But there is always the added patch I could get just to confirm the use of Cardizem or electronic therapy.

And what most of all of you don't realize is corticosteriod use in ARDS / Pneumonia / Sepsis patient's actually significantly increase their chance of surviving out of hospital. In fact it's standard treatment for ARDS / Pneumonia including minimal doses of methlypredisnoe, high dose anti-botics. A fluid bolus in this situation is on the fence. Because more of the fluid could rehydrate the patient, however the patient could also end up drowing in the narrow passage ways that are created due to the mucus back up in the bronchioles and aveloi.

Myself, I would of gave the cardizem ( I would of probably checked with Medcom just before to make sure I was right in my thinking), and gave the sol-u-medrol and transport with oxygen.

[crotchitymedic1986]

Here is a perfect example of cookbook medicine where rookies treat the monitor instead of the patient (which is the type of medic your preceptor is == it happens). The rate will come down as soon as you get the fever amd hypoxia under control. If you do not have oral antipyretics, I am sure the nursing home had suppositories they could have given you. Treat the fever, treat the dyspnea, give some IV fluid, and the patient will be fine.

*** I imagine the ER doctor didnt ask you why you didnt give cardizem, and I imagine he/she didnt administer it either.

Kudos for being an exceptional rookie.

[CTXMEDIC]

Here is a perfect example of cookbook medicine where rookies treat the monitor instead of the patient (which is the type of medic your preceptor is == it happens). The rate will come down as soon as you get the fever amd hypoxia under control. If you do not have oral antipyretics, I am sure the nursing home had suppositories they could have given you. Treat the fever, treat the dyspnea, give some IV fluid, and the patient will be fine.

*** I imagine the ER doctor didnt ask you why you didnt give cardizem, and I imagine he/she didnt administer it either.

Kudos for being an exceptional rookie.

OMG, THANK YOU!

I had a long way to read to get to a common sense post.

I have a few questions about this case. what was her PULSE rate, forget what the monitor says, shes in a-fib, of course its going to read between 180-210. HEART RATE and PULSE rate are 2 different things. cardizem is used in a-fib with RVR which this patient, apparently, was not experiencing as she was hemodynamically stable. Cardizem would have been absolutley the wrong choice. being that she was also experiencing SOB and fever a fluid bolus would have been the correct route secondary to dehydration (do you remember what her vitals were?)

as she was satting around 98 on 4lpm, i dont think i would have given the Neb, maybe maybe not, it would depend. but NOT because of her 'heart rate'.

id like to see her med list as well.

what you had here was a granny with chronic a-fib that has pneumonia a fever and probally dehydrated to boot. you need to find another preceptor, IMO. Congrats for recognizing something 'just didnt seem right' about this case and following up on it. good luck.

[ERDoc]

Crotch, as usualy you are the one praciticing the cookbook medicine. Many situations in medicine do not have one correct answer. A heart rate of 170-210 is not from a fever or sepsis. You are dealing with afib with RVR. The sepsis is already stressing the heart. Letting it ride at 3 times it's normal capacity is just adding more stress to it. You are just asking for trouble. The pt's body is not functioning properly and as such, you as the provider need to take control. Please stop with the crap about treating the pt and not the monitor. The monitor represents a part of the pt (a very important part at that). You need to treat the part of the pt that is not functioning properly. Give the cardizem, give your fluids, give antipyretics and treat the pt properly. No ones heart should be beating that fast and it should not be left to collapse when you have the ability to treat the problem.

I would also avoid the albuterol for the cardiac affects. Xopenex can be a suitable alternative. Steroids are effective in treating sepsis, especially if your pt is already on chronic steroids (they may even require a stress dose). Cardizem with help with the heart rate and help prevent an MI, but it may also convert the rhythm back to sinus (possible side effect), but it the pt has chronic afib I doubt this will happen.

[CTXMEDIC]

For the love of all thats holy and good.

You guys are acting like youve never seen an a-fib patient on the monitor. it ALWAYS jumps around, sometimes a little more, sometimes a little less. it is NOT the true 'heart rate'. you can have a 'heart rate' of 180-210 and a pulse of 60. Just because the sa node is wangin away at 180 doesnt mean the the ventricle is. It would be nice to have the strip but oh well.

original post

Pulse Ox is 92% on monitor, Monitor Rapid A-fib rate of 170-210 at times. still no other complaints

If she was actually RVR, we'd be seeing SOB, hypotension, rapid QRS...just cuz the monitor say 'x' doesnt make it so. i can make v-fib by rolling the lead cord under my foot.

THIS is A-fib with RVR

PS. ERDoc is correct that fuid will not change this rhythm or rate. the rate is an electrical issue, not an issue of compensation.

[ERDoc]

For the love of all thats holy and good.

You guys are acting like youve never seen an a-fib patient on the monitor. it ALWAYS jumps from 180-210, sometimes a little more, sometimes a little less. it is NOT the true 'heart rate'. you can have a 'heart rate' of 180-210 and a pulse of 60. Just because the sa node is wangin away at 180 doesnt mean the the ventricle is. do we really need to give a class on basic cardiology?

READ the original post.

Pulse Ox is 92% on monitor, Monitor Rapid A-fib rate of 170-210 at times. still no other complaints

If she was actually RVR, we'd be seeing SOB, hypotension, rapid QRS...

You have obviously never taken care of many pts with afib. You can have a high ventricular rate and still be asymptomatic. If you read the original post, there was no mention of what the pulse rate was so you are making assumptions and possibly false ones at that. Afib does not "ALWAYS" jump to 170-210. Take a real cardiology course and get back to us. In afib the SA node it not doing much of anything which is why we have atrial fibrillation. There are multiple ectopic atrial foci producing an atrial impulse. When you give a heart rate in pts with afib, you are giving the ventricular rate as there is no true atrial rate. You may only palpate a pulse rate of 60 but that does not mean that the ventricle is not being whipped (this is a case where ignoring the monitor as has been proposed may be a fatal error, good luck defending it in court). With a rate like that there is not enough time for the ventricles to fill and you will not feel a pulse. The output that is being supplied by the palpable beats may be enough to keep the pt hemodynamically stable for now which is why she does not have any symptoms. Continue beating on your ventricles like this and they will shortly give out. It is apparent from your posts that you need a review of cardiac physiology, please do not post inaccurate info and confuse the people that are trying to learn. I was willing to give you the benefit of the doubt when you first came, but the more posts you add the more it becomes apparent that you and crotch are a natural fit.

[CTXMEDIC]

Here is a perfect example of cookbook medicine where rookies treat the monitor instead of the patient (which is the type of medic your preceptor is == it happens). The rate will come down as soon as you get the fever amd hypoxia under control.

No it wont. Shes in A fib. and with a sat of 98%, no SOB and aox4, why do you think shes hypoxic?

[CTXMEDIC]

You have obviously never taken care of many pts with afib. You can have a high ventricular rate and still be asymptomatic. If you read the original post, there was no mention of what the pulse rate was so you are making assumptions and possibly false ones at that. Afib does not "ALWAYS" jump to 170-210. Take a real cardiology course and get back to us. In afib the SA node it not doing much of anything which is why we have atrial fibrillation. There are multiple ectopic atrial foci producing an atrial impulse. When you give a heart rate in pts with afib, you are giving the ventricular rate as there is no true atrial rate. You may only palpate a pulse rate of 60 but that does not mean that the ventricle is not being whipped (this is a case where ignoring the monitor as has been proposed may be a fatal error, good luck defending it in court). With a rate like that there is not enough time for the ventricles to fill and you will not feel a pulse. The output that is being supplied by the palpable beats may be enough to keep the pt hemodynamically stable for now which is why she does not have any symptoms. Continue beating on your ventricles like this and they will shortly give out. It is apparent from your posts that you need a review of cardiac physiology, please do not post inaccurate info and confuse the people that are trying to learn. I was willing to give you the benefit of the doubt when you first came, but the more posts you add the more it becomes apparent that you and crotch are a natural fit.

good job 'Doc', you just propped up my assertion. 'heart rate' means squat when read by a monitor, it is a tool, not gospel.

now good doc. tell us why you would cardiovert a hemodynamically stable patient with chronic a-fib based on a monitor thats showing a rate of 'whatever'. assuming she has a good strong pulse and good blood pressure of course. BTW, im not here looking for your good graces, as for the amount of a-fib patients ive seen over the years? quite a few as i work in an area with a large geriatric population. oh, and i havent killed one yet...

as for the 'always', my appologies, i was only trying to get acrossed to the young lad that on a monitor, the rate is constantly changing. without seeing the patient myself, knowing her vitals and seeing the strip all you can do is ASSume as well. with your vast cardiac experience youd know that a monitor shows electrical activity, not mechanical activity, right?

[CTXMEDIC]

[quote="ERDoc

When you give a heart rate in pts with afib, you are giving the ventricular rate as there is no true atrial rate. You may only palpate a pulse rate of 60 but that does not mean that the ventricle is not being whipped (this is a case where ignoring the monitor as has been proposed may be a fatal error, good luck defending it in court).

[Niftymedi911]

CTX grow the hell up and stop acting like an arrogant <..........> Your type is the main reason why we're not looked @ as a profession..... cocky, arrogant, and failure to see the big picture.

Now, what in the OP suggests this patient is not hypoxic?? Is it just because "she's @ 98% on 4 lpm"? Are you even seriously thinking this through. A normal person would not need supplemental oxygen @ 4lpm to have their O2 saturations @ 98%. The damage the chronic pneumonia has caused to the lungs is already enough to suggest VERY mild hypoxia under normal conditions. Now with her lungs compromised by the infection again and not to mention tachypnic why would she not be hypoxic?? Oh my bad, you don't treat the monitor (aka magic box as you call it). But it sure as hell sounds like it to me.

The whole compensatory tachycardia added : "don't touch it", does not apply here. A-fib and a compesatory tachy are two seperate things. Just because she has a high HR with "stable" vital signs (which is what your getting stuck on), does not mean its a compensatory tachy. But when you decide to ignore it and she becomes hypotensive, AMS, cyanotic with circumoral cyanosis, your causing harm that could of been avoided. As ERDOC put it, Good Luck with trying to defend a Tort Law case. Your arse will go through the ringer.