Rapid A-fib / Pneumonia / Cardizem

[Camulos]

Yes, absolutley without a doubt. But when we have a poster that says his monitor is showing an irregularly irregular rhythm, the numbers it throws up as a rate mean squat. every and i mean EVERY patient i have had in a-fib shows 'rates' all over the map..anywhere from 120 to 300 something and i will NOT EVER use those numbers as a basis to treat a stable patient for a 'maybe'. i dont push drugs because i can or because the good book says so. our 'doctor' is telling us that matching a pulse to the monitor is a dumb idea. so basically if i feel a nice strong radial pulse and it matches exactley what my monitor is presenting as a rhythm, 1 QRS per pulse, im not to believe it. this guy must be a proctologist.

I fully agree we should treat pt's and not monitors - NO argument there. In fact I am constantly pulling people up for that very problem. You would be amazed how many people commence treatment on an asystole algorhythm when I sneakily (is that a word?) remove the electrodes during scenario training.

Having subsequently just read the clinical obs of this pt, HR 88bpm and BP 130mmHg, the correct decision would be NOT to give the cardizem. Comes back to the contraindications I mentioned earlier. I guess CTXMEDIC was just asking for more info before deciding whether to give the cardizem or not. And that information was critical in this case, so in that sense he was ultimately correct in making the decision not to give cardizem before assessing the pts pulse rate. Unfortunately I think it is sometimes difficult to decipher his real point amongst all the politics. I'm not having a go here though and believe it takes all sorts to make a world, or a forum topic. At the very least he keeps it interesting that's for sure.

Great topic and I'm sure we all learnt a lot from it.

Stay safe,

Curse :evil:

[ERDoc]

Thank you. Good job 'DOC', you just killed your patient. Notice the part where he says ATRIAL RATE

Oh how wrong you are. Again, you have shown that you need to take a cardiology course. If this truly was afib then there is no atrial rate. You can not get a rate from a fibrillating chamber. Dude, afib is going to a show a rate that is all over. That is normal in afib as you get inconsistent transmission of impulses through the AV node. The whole reason you are giving for ignoring is basically the clinical definition of afib. Again, when you get a clue feel free to post, til then leave the education to those that know what they are talking about.

Curse, thank you for pointing out what I said. You are right, that is not a reason to give it, but the lack of evidence to not give it is pretty compelling. I will respectfully ask you to post the studies that you bring up for the better education of everyone here.

Crotch, I'm not sure if that was supposed to be an insult but based on your past I assume so. So what if I was educated in Guatemala? The fact is I have an education. Even docs from foreign schools need to pass basic US exams to be able to practice. Education still beats training everyday. Sorry to let you down, but no, I was not educated in Guatemala. I was born, raised and educated in the great state of NY, a stones throw from NYC.

As I stated before, there is more than one way to treat a pt. This is just such a case. The pt did well without cardizem. A more aggressive doc would have given it and probably had the same outcome. Again, a lot of this hinges on what the EKG initially showed. If there was an atrial rate of 180-210 then this is clearly not afib and cardizem may not be the best choice.

[CTXMEDIC]

If this truly was afib then there is no atrial rate. You can not get a rate from a fibrillating chamber. Dude, afib is going to a show a rate that is all over. That is normal in afib as you get inconsistent transmission of impulses through the AV node. The whole reason you are giving for ignoring is basically the clinical definition of afib.

which is EXACTLEY my point. So tell the class why YOU, a supposed physician, are going to block this ladies calcium channels based on bogus rate numbers alone.

[Camulos]

Oh how wrong you are. Again, you have shown that you need to take a cardiology course. If this truly was afib then there is no atrial rate. You can not get a rate from a fibrillating chamber.

Unfortuantely I disagree with this one too. You can TECHNICALLY get an atrial rate from AF. It is extremely difficult though and even using advanced methods does sometimes come up as "umeasurable" - depending on certain factors. As you want references here you go;

http://www.cinc.org/Proceedings/2008/pdf/0829.pdf

I do recognise this is a moot point though and is not clinically significant for us at the bedside as we do not have the ability to measure the atrial rate as they did in this article. Who knows, perhaps Welch periodogram's will become standard in all ambulances and ER's. :wink:

Stay safe,

Curse :evil:

[ERDoc]

which is EXACTLEY my point. So tell the class why YOU, a supposed physician, are going to block this ladies calcium channels based on bogus rate numbers alone.

Because the rate that you are getting from the monitor is your ventricular rate, not the atrial rate. As I said, there were certain assumptions that we had to make in this case. If you are getting one QRS with every pulse then obviously the number given by the monitor is wrong. I am assuming that if the OP is telling us the the monitor showed a rate of 180-210 that there are the corresponding QRSs. If this assumption is wrong, then I will concede that cardizem might not be the best choice. As you said before certain assumptions need to be made based on a case scenario on the internet. This may be where you and I are having our differences. I am assuming that the equipment is working properly and that the OP has correlated the given rate with the appropriate complexes.

Curse, you are correct again. In theory you can get an atrial rate even in afib, but clinically speaking it is impossible.

[CTXMEDIC]

so we agree to disagree

in MY prehospital experience, when i have an a-fibber on a monitor the numbers dont correspond with ANYTHING, its like watching a slot machine spin, "wheres it gonna land?" I also agree, cuz it is correct, that when you are getting a good reading on the magic box, the numbers correspond with ventricular rate but in a-fib this is a moot point. i also learned long ago never to 'assume' anything regarding a patients condition. if i just assumed everything i wouldnt be practicing medicine.

anyways, take care.

[crotchitymedic1986]

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

Answer:

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.

Her O2 sat increased with OXYGEN -- on room air she is satting 80s-low90s, and has atleast one lung full of sputem. The patient does not have a cardiac issue, she has a respiratory issue. If not treated, it could become a cardiac issue, but you should treat the underlying cause first.

[Mateo_1387]

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.

Thanks for posting the scenario. These long discussions are what the city is about !

We are fortunate to have Solu-Medrol.

The first paragraph is a bit confusing. Are you saying that cardizem is indicated for a rapid ventricular rate, and then immediately contraindicated due to the possibility of clot formation within the atria? Using cardizem is a judgment call. For a patient that has strong clinical indication of becoming "unstable" I feel cardizem should be used. I understand there is the chance of conversion with Cardizem, but that is not the norm. Cardioversion usually requires premedication with anticoagulants, and then electrical cardioversion. Again, it is a judgment call. You have a patient who will most likely become unstable, so we want to prevent it the best possible way. Kind of a risk vs. benefit argument. Electrical cardioversion would be a last resort because conversion to sinus rhythm could cause a clot to enter systemic circulation. Electrical cardioversion would be used on an unstable patient. For the unstable patient, the risk vs. benefit would favor hemodynamic stability, in light of a clot being released into systemic circulation. Even better treatment would be to control rate with antiarrhythmics, if indicated. If able to use antiarrhythmics, but use electrical conversion, the cardioversion would be riskier. Clear as mud?

Just some more on the point about treating the monitor vs. the patient. In cases where the pulse rate is within normal range, yet on the monitor you count a ventricular rate that is 3 times the normal limit, I would be inclined to treat with cardizem. You have to remember that all ventricular complexes may not equal the pulse rate. Although I have not been exposed to such as case, ya never know. Also, since the heart monitor does view electrical activity, and not mechanical activity, it would be important to listen to the heart and hear if the heart rate matches the number of QRS complexes. For us to see electricity being transmitted through the ventricles (a QRS complex) there is probably going to be mechanical movement of the heart, although possibly not very strong. Such as a PVC, you've heard of PVC's that produce a pulse and those that don't, does not mean that the heart is not moving.

This patient will benefit for critical thinking and not cook book medicine. Out treatments need to be guided by clinical evidence. Blanket statements such as treat the patient not the monitor are bogus. Treat the clinical picture. Expect the unexpected, and be educated enough to do the best for your patient with presented with an unclear clinical picture.

And to crotch, patients can exhibit multiple clinical problems with multiple etiologies. Not everything is dependent on just one medical problem, all the time. Just sayin'.

[crotchitymedic1986]

Most nursing home patients do present with multiple problems, which is why you treat the patient. This is the best example of cook-book I have seen in awhile:

The monitor says she has a rate of 200, lets cardiovert her or give her cardizem -- wait a minute, her mechanical pulse is only 88.

She's not hypoxic, because my pulse ox says 98%.

Havent seen anyone suggest treating her fever. I know a tylenol suppository or a shot of toradol isnt as sexy as cardizem, but it should be the "FIRST" treatment in this scenario (after O2).

I couldnt have written it any better.

[CTXMEDIC]

Most nursing home patients do present with multiple problems, which is why you treat the patient. This is the best example of cook-book I have seen in awhile:

The monitor says she has a rate of 200, lets cardiovert her or give her cardizem -- wait a minute, her mechanical pulse is only 88.

She's not hypoxic, because my pulse ox says 98%.

Havent seen anyone suggest treating her fever. I know a tylenol suppository or a shot of toradol isnt as sexy as cardizem, but it should be the "FIRST" treatment in this scenario (after O2).

I couldnt have written it any better.

as i previously posted, a 98% sat is not my ONLY indication that this patient isn't hypoxic. could her ABG come back with a 99%? if so shes 'hypoxic', right?