Rapid A-fib / Pneumonia / Cardizem

[scott33]

I'm a little late to this one but I think I'm joining the "would give cardizem" camp

Me too.

For those who don't know, or don't care - Cardizem would be one of the first medications that would be given in the ED in this scenario, whether the patient presents "completely stable" or otherwise.

[medic_texas]

We do cartizem drips and dig all of the time for patient's with a-fib who go into rapid a-fib (both ICU and ER). I'm just amazed at some of the responses people are giving here.

My experience - education will outweigh an ego any day.

[Arizonaffcep]

We do cartizem drips and dig all of the time for patient's with a-fib who go into rapid a-fib (both ICU and ER). I'm just amazed at some of the responses people are giving here.

My experience - education will outweigh an ego any day.

And if it doesn't, the "Because I'm your medical director" line (while distasteful) can be kicked into play.

[celticcare]

I am torn on this one too, part of me wants to go down the lets give Cardizem path, but the other is treat the underlying issue, the initial complaint was SOB with Pneumonia compounding everything. Then the Afib showing a fluctuating rate on the screen as 170 +bpm and an associated palpable pulse of 88. She is normotensive in a textbook sense *or could be her response to beta blocker bp*.

Part of me wants to go down the path of lets cardiovert her "either chemically or electrically" but she is "stable" in the essense of GCS 15/15 and holding her bp. Without knowing if she had taken her BB, when she took it, what the afib itself looked like on the monitor and potential to deteroirate is like. Also what her body mass and general apperance was like would be a factor for me on giving the medication. Co morbidities also, had she had any anti hyperglycemic medications?

Its a tough call, an hour out from hospital, yeah probably would have seriously considered cardizem for the issues of cardiac intergrity etc, but close to hospital, unless she was looking like she was going to code or crash on me, i would withhold the cardizem.

Some excellent points raised here, some egotistical issues raised and some definate "my wangers bigger than yours" posts, but I wonder whether as much debate would have arisen if the other information on pulse rate, temp etc were included in the initial post?

[CBEMT]

Brought in a nursing home patient in Rapid A-fib one day, hypotensive but not critically so. ER doc decided she wasn't critical enough to electrically convert, but was too hypotensive to hang Cardizem on. Doc seemed stumped (not surprising given the facility).

Five minutes later, the patient rolls over, vomits, and converts back to NSR. The doc was pleased.

[emt322632]

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

I would opt to give the cardizem, rate control while attempting to treat the underlying condition (poss. dehydration secondary to infection, hypoxia r/t infection etc. etc.) Her rate is very concerning. She may be stable now, but there is only so much that a heart that old can take, and I'm assuming she has other comorbidities as well which weren't listed.

Hypoxia and infection increase the heart rate, putting more strain on the heart in an attempt to get more oxygen to tissues deprived of it. However with a rate this high the heart isn't doing itself any good, the ventricles can't fill completely and sooner or later she will decompensate. I would have consulted with med control on this but I'm going to lean toward administering the drug, while attempting rehydration.

Found a very good article on treatment of rapid a-fib:

http://www2.nursingspectrum.com/articles/a...le.cfm?aid=5861

In the article it says that treatment is, "...aimed at controlling and slowing the ventricular rate, treating the underlying cause, preventing embolic stroke, and restoring normal sinus rhythm..."

It doesn't say "Well we'll assume this is a respiratory problem and treat as such without worrying about the cardiovascular side effects..."

Treat the rate, while treating the underlying cause...

[spenac]

As a student I was shocked that so many fail to realize that even though supposedly stable at the time that if left in this condition will rapidly become unstable. Because of beig stable you have the option of using Cardizem rather then adenisone or shocking to reset. Stay ahead of you patients and avoid having to work so hard. Much easier to treat while "stable" than after they go south.

[emt322632]

As a student I was shocked that so many fail to realize that even though supposedly stable at the time that if left in this condition will rapidly become unstable. Because of beig stable you have the option of using Cardizem rather then adenisone or shocking to reset. Stay ahead of you patients and avoid having to work so hard. Much easier to treat while "stable" than after they go south.

Completely agree...I'd rather be in front of the 8 ball than behind it...