Intermittent Atrial Fib

[1EMT-P]

You are called for a 65 year old female patient complaining of increased shortness of breath. Upon arrival you find her sitting on her couch. She is on oxygen at 3 LPM. She tells you that she has been experiencing increased shortness of breath times 24 hours. She states that it started after going outside in the cold. She is conscious, alert & oriented, her skin is pale, warm & dry & her & pupils is equal & reactive. Upon further exam you note no JVD, trachea is midline. Patients lung sounds reveal wheezes. Her abdomen is soft, non tender & slightly distended. Patient has good cms. Patients vital signs are as follows BP 136/66, Pulse 137, Respiratory Rate 22. Patients Finger Stick is 118, Pulse Oximetry is 96% & her EKG reveals an Atrial Fib at a rate 137 with pacer spikes noted. She tells you that she has a history of Intermittent Atrial Fib, Hypertension, High Cholesterol, Tachy-Brady Syndrome, Pulmonary Hypertension, Mild Leaky Heart Valves x4, Asthma, Dual Chamber Pacemaker, GERD & Anxiety. Her medications include Albuterol MDI PRN, Dulera MDI, Lasix 40mg BID, Aspirin 162mg BID, Zantac 150mg BID, Zoloft 75mg QD, Zocor 10mg QD, SL Nitro 0.4mg PRN & Metoprolol 100mg BID. You have a 30 minute ETA to the ER. So what do you do?

[Kiwiology]

Give her some salbutamol and take her to the hospital

[Just Plain Ruff]

IV O2, Monitor, breathing treatment, protocol monkey's UNITE!!!!!!

Could this be cold induced bronchospams?

[island emt]

Initially I had the same thought Ruff: But the fact that it started 24 hrs earlier after a trip outside makes me wonder about other pathophysiology behind this call.

Initial impression based on info given would point towards possible pneumonia or bronchial infection. We don't have a temp so would get that and go from there . With the vitals that are noted , she would definitely get a 12 lead and IV access along with ETCO and see how well she is actually moving air.

My gut tells me she is a sick pt that needs transport.

HX of pulmonary hypertension makes me a little edgy here.

Don;t think I'm going to jump on giving breathing TX right off the bat, even though she is wheezy.

Don't see an anti coagulant in her meds list that one would expect to see with A-fib HX.

[mobey]

I'm going with a few puffs from MDI, and a trip to the er.

Watch for edema post MDI admin.

[rock_shoes]

Agreed on the Ventolin/Atrovent.

Anyone else thinking we should consider a beta blocker or a CCB with a 30 minute transport time? Worth giving the Doc a ring and having the discussion anyway. She's already paced so it's lower risk than most patients (a demand pacer considering the ECG findings being shared) and based on her history we're probably looking at an a-fib less than 48 hours old. I'm surprised her medications don't include coumadin or dabigatran. I'm leaning more toward a CCB over a beta blocker in this case with signs of bronchospasm also presenting (I know in Alberta it's metoprolol or metoprolol but a guy can dream).

[ERDoc]

Agreed on the Ventolin/Atrovent.

Worth giving the Doc a ring and having the discussion anyway.

RING-RING-RING. Yes, this is Dr. ERDoc. I'm sorry we are having a communication failure and I cannot hear you. You will have to manage this pt on your own. See you soon. CLICK

[rock_shoes]

RING-RING-RING. Yes, this is Dr. ERDoc. I'm sorry we are having a communication failure and I cannot hear you. You will have to manage this pt on your own. See you soon. CLICK

Alright then. First ensure the rate isn't compensatory. Any recent illnesses? Has she spiked a temp? Does anything lead you to believe this patient may be septic (skin infections, chronic respiratory infections, UTI's)?

After that, provided she isn't allergic to it, verapamil 100mcg/kg SIVP is worth a go. Follow it up with verapamil 150mcg/kg SIVP 15-30 minutes later if the first dose doesn't do the trick. Anything under a 110 BPM for rate is going far enough in this case. No point putting that pacemaker safety net to use if you don't need to. Monitor closely for hypotension. A small fluid challenge is worth doing prior to the verapamil. It's amazing what a little fluid can do sometimes.

[Kiwiology]

For somebody with HTN a BP of 136 is probably a bit low especially considering she is beta blocked.

If she has no compromise then on a 30 minute trip to the hospital I do not see the point of getting all carried away and doing things that are not necessary.

For now that's my story and I am sticking to it.

What is her temperature?

[mobey]

Verampimil with Metoprolol?

How dare you!!