Afib RVR

[scmedic2016]

Afib RVR patient with chest pain. First attempt was to treat the rhythm which failed because we only carry adenosine. Vs were fine so no electricity. Patient was then treated with nitro and ASA. I've heard people go either way with this, some would give the nitro and ASA and some wouldn't. Any thoughts? 

[paramedicmike]

Welcome. 

A case discussion!  Excellent!

What did the 12 lead show?  Rate? History of AF?  Or is this new onset?  You mention that vitals "...were fine so no electricity" yet you describe a symptomatic patient.  Do you think this was a stable patient?  Did your treatment of GTN and ASA do anything?  If you identified AF on EKG why try adenosine?  Is adenosine indicated in AF?  What adverse reactions can happen if you give adenosine to an AF patient?

[scmedic2016]

Rate was 160 to 180. Unknown history of afib. Bp was 110 systolic. This wasn't my patient instead a supervisor of mine. Not sure what the 12 lead showed. Just heard his radio report. I'm going to assume with the rate so fast it looked regular and once he administered adenosine it slowed down enough to see afib. I know its vague  because I don't have much information but it brought up a good discussion. 

[Off Label]

Sounds like, lacking any ability to get the HR down, the idea was to increase myocardial O2 delivery with the nitro? Not a chance I would have been comfortable with personally given no atrial help and the fall in stroke volume from that rate.  The patient sounded like he was flirting with needing CV, but giving the NTG could force your hand in that.

I'd punt to the ER for pharm control if the transport time allowed, trying to avoid CV if possible.

[scubanurse]

Sounds like a healthy dose of diltiazem is in order.  Do you guys carry it?  If so, let's have a discussion on pre-hospital use of Dilt.

[paramedicmike]

On 12/30/2016 at 3:00 PM, scmedic2016 said:

Rate was 160 to 180. Unknown history of afib. Bp was 110 systolic. This wasn't my patient instead a supervisor of mine. Not sure what the 12 lead showed. Just heard his radio report. I'm going to assume with the rate so fast it looked regular and once he administered adenosine it slowed down enough to see afib. I know its vague  because I don't have much information but it brought up a good discussion. 

You're looking for discussion but you're not discussing.  So what is it you want to know?  What kind of good discussion did it bring about?  What is it you're looking for from us?  Despite the immensely vague nature of your posts there are some excellent points of discussion to be made.  For example:

1) What's the goal of treating AF?

2) How do you reach that goal?

3) Do the interventions you stated were undertaken with this patient have any purpose?  Is it even indicated?

[scmedic2016]

2 hours ago, scubanurse said:

Sounds like a healthy dose of diltiazem is in order.  Do you guys carry it?  If so, let's have a discussion on pre-hospital use of Dilt.

We don't carry it. I've never worked for a service that does so I have no experience with diltiazem. I know they have looked at getting it on our trucks. But we have not gotten to that point. 

1 hour ago, paramedicmike said:

You're looking for discussion but you're not discussing.  So what is it you want to know?  What kind of good discussion did it bring about?  What is it you're looking for from us?  Despite the immensely vague nature of your posts there are some excellent points of discussion to be made.  For example:

1) What's the goal of treating AF?

2) How do you reach that goal?

3) Do the interventions you stated were undertaken with this patient have any purpose?  Is it even indicated?

I'm just asking about nitro and ASA for a patient complaining of chest pain with afib RVR with a rate between 160 - 180. But I got an answer. And I know its vague. Which is why I said the information is vague. I wasn't the medic on the call so I don't have much information. He treated the patients with nitro and ASA and I've never heard of that for a patient in afib rvr. But like I said I got an answer so thank you for your time. 

[ERDoc]

This is where blindly following protocols is bad.  Yes, the pt c/o chest pain but why might that have been?  Hearts weren't made to run at a rate of 160-180 so there might have been some ischemia, but it is most likely rate related.  There is not much use for ASA or ntg in a case like this.  You want to get the rate down.  I'd be very cautious about converting (ie, I wouldn't convert)  since we don't know the onset.

[rock_shoes]

ERDoc makes two excellent points in this case. First off, blindly following protocols can be dangerous for patients. Secondly, patient history is needed for sound clinical decision making in this case (was onset within the last 24-48 hours? do you have the option of rate control with a calcium channel or beta blocker?).

[Spock]

I can think of any number of drugs to give this patient and none of them include NTG or ASA.  ERDoc is certainly correct in that this is rate related and with the a SBP of 110, the patient leans toward stable rather than unstable although that may not be the case for very long.  Diltiazem is the drug of choice here followed by beta blockers, amiodarone, and perhaps verapamil.  My service carries diltiazem and amiodarone but not beta blockers or verapamil.  I wish we carried a beta blocker such as esmolol, lopressor, or labatelol.  

The last patient I had go into AFIB with RVR was under general anesthetic and already in a lateral position for a video assisted thoracoscopy.  When prepping the patient, I had placed the defib pads on him because he was sicker than crap.  Just before incision, the rate took off into the stratosphere and the BP as measured by my arterial line dropped like a rock.  The last numbers I saw was a rate of 180 and a SBP of 50.  I sync cardioverted with 200j and knocked him into sinus rhythm.  The surgeon was quite happy and we finished the case after cleaning the infection out of his chest.  He had a rocky ICU course but survived.  The risk of cardioversion is dropping a clot into the brain and stroking out but there really was no choice here.  

May the Tube be with you

Spock