Complex cardioversion?

[1EMT-P]

I would assess the ABC's, Start the patient on O2, Start an IV of NS@KVO & Place the patient on the Cardiac/SPO2 Monitor. I would also consider giving the patient an Albuterol+Atrovent Nebulizer treatment for his COPD/SOB and # 4 Chewable ASA if he was having any signs or symptoms of Angina or AMI. I would also consider giving the patient a trial of either Diltiazem 0.25mg/kg IV over 2 minutes up to 20mg or Metoprolol 2.5-5mg IV over 2-5 minutes to a max. of 15mg. If the patient did not respond to a trial of medication then I would sedate him with 2.5-5mg IV Valium and use synchronized cardioversion starting at 100J.

[Thunderchild145]

I would assess the ABC's, Start the patient on O2, Start an IV of NS@KVO & Place the patient on the Cardiac/SPO2 Monitor. I would also consider giving the patient an Albuterol+Atrovent Nebulizer treatment for his COPD/SOB and # 4 Chewable ASA if he was having any signs or symptoms of Angina or AMI. I would also consider giving the patient a trial of either Diltiazem 0.25mg/kg IV over 2 minutes up to 20mg or Metoprolol 2.5-5mg IV over 2-5 minutes to a max. of 15mg. If the patient did not respond to a trial of medication then I would sedate him with 2.5-5mg IV Valium and use synchronized cardioversion starting at 100J.

Isn't Albuterol contraindicated with a rate that fast?

[678 Responding]

I think i'm going to have to agree with the whole oxygenation/heart rate treatment together. He is having such a rapid A-fib due to the hypoxia. Why not treat both at the same time? I think he his having the edema from the blood backing up due to decreased cardiac output. I would throw him on Sp02, ETCO2, CPAP, and try to get his oxygen saturation up as high as I can while trying to keep CO2 under control. I also think the use of albuterol might excasorbate the situation, causing more myocardial oxygen demand, making everything worse. But does the risk outweigh the benefits? How about 125mg of solu-medrol? Atrovent would be good too, but I dont think it's going to do much.

Also, since this is an obvious unstable A-Fib, if the oxygenation doesn't help bring the rate down, either use Diltiazem .25 mg/kg, if that doesn't do anything, sedation and cardioversion is going to be needed. Regardless of whether or not he's on blood thinners, if you don't control the rate, he's going to eventually die. Chances are, since he has chronic a-fib he's probably on a blood thinner like coumadin already, but if he does throw a clot, you can always treat that afterwards. But I also agree, if you try to convert or control this rhythm without massive re-oxgenation, you're going to be wasting your time because you will have no response from drug therapy, and a not so nice V-fib or Asystole from electrical therapy because the cells don't have enough energy to repolarize after a "reset". Tricky topic. Good one though, keep it coming.

[ERDoc]

I would assess the ABC's, Start the patient on O2, Start an IV of NS@KVO & Place the patient on the Cardiac/SPO2 Monitor. I would also consider giving the patient an Albuterol+Atrovent Nebulizer treatment for his COPD/SOB and # 4 Chewable ASA if he was having any signs or symptoms of Angina or AMI. I would also consider giving the patient a trial of either Diltiazem 0.25mg/kg IV over 2 minutes up to 20mg or Metoprolol 2.5-5mg IV over 2-5 minutes to a max. of 15mg. If the patient did not respond to a trial of medication then I would sedate him with 2.5-5mg IV Valium and use synchronized cardioversion starting at 100J.

You want to give beta blockers to someone with bad COPD???

[ERDoc]

Isn't Albuterol contraindicated with a rate that fast?

If you are going to chemically control the rate, I wouldn't worry about it. You are almost maxing out heart rate as it is in this case. I don't think any more sympathetic or any other form of input is going to drive the rate up. The heart is at the point where it is depolarizing as soon as it is out of the refractory period. You've got to treat the lung problem also. I don't think this case can be sliced nicely with Occams Razor.

[firefighter523]

Albuterol is the wrong tx to this person. And I don't have any idea why you would give someone solu-med considering it takes all of about 6 hours for that to take affect. The problem, which you can't rule out, therefore you need to fix, is his rate. He is probably hypoxic because of his pulmonary htn, and the lack of oxygenation to his tissues, do to the lack of filling of his ventricles. You could put someone on high flow all day long, but if it is not getting delivered properly it is just being wasted.

And another point, he does have a hx of COPD, do you treat the wheezing from the underlying lung disorder, or is it cardiac asthma??? Fix the rate, release some of the pulmonary pressure, see if the rales decrease, I am betting they would. Beta agonist to a sick heart is a bad idea.

[sledogg1]

Didn't see the CHF point...........but still a unstable A-fib cardiovert.

abc's

If not go down the line for CHF

>92% O2 SATS Nitro,salbutamol,morphine,lasix

<92% O2 SATS Salbutamol,morphine,nitro,lasix

Laxix only if he is on it.

[emt322632]

I would have gone down the CHF route as well with the presentation. Gradual 2 day onset, positional dyspnea, pitting edema...with that pressure though I would avoid the lasix and nitro and instead opt for CPAP.

He's in a bad way, no doubt about it, in protocols here we can't shock unstable A-Fib. If the above treatment didn't work, maybe some cardizem or adenocard to attempt to slow the rhythm. Definitely consult med control.

[sledogg1]

CPAP is good as with he's age and all..........intubation would be hard to ween off and the pt would probably expire. CPAP requires alot of 02 will drain a m-tank in 15 mins our infield studies and research here in NS was positive but looking at the o2 SITRAP had very good outcomes.............I have a call area with a 25-30 response time in rural Nova Scotia, the city great, country bad. Thats why the Nitro and Lasix, wonderfull believe me it works for the CHFer wonderful stuff except no rubbersheets on board .

Chris

[1EMT-P]

The Relative Contraindications For Beta Blockers Are:

1. Asthma

2. Bradycardia (Less Then 60 BPM )

3. COPD

4. Hypotension

5. 2nd or 3rd Degree Heart Block.

Beta Blockers were once believed to be contraindicated in patients with CHF, but now they are considered first line treatment for patients with mild to moderate CHF. There have been several large studies done that have shown that Beta Blockers actually decrease mortality in patients who are already on heart failure medications like ACE Inhibitors and Diuretics with or without Digoxin.