# A-fib with RVR



## Macari (Feb 24, 2009)

This might make me sound like an idiot but hear goes,

Working with a Medic and had a CP call. Patient had heart rate of about 80 and with regular R-R and to me what looked like a little artifact between QRS (working with an old Lifepack 10 that takes a while to warm up and hasent had time to yet). This medic insisted that it was A-fib with RVR.

First of all I dont agree that it was A-fib. Secondly I have never heard of A-fib with RVR (maybe I missed that lecture in cardiology). She explained it as A-fib with rate over 60 because A-fib is a ventricular rhythm. WHAT!!!

Now can anyone give me a better explanation for RVR?

Thanks
Tony


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## artman17847 (Feb 24, 2009)

first lets start with the basics was the rhythm regular or irregular?

if its irregular then most likely the underlying rhythm is a-fib

now a-fib with RVR (rapid ventricular response) is a tachyarrithmia and thus the rate will be 100bpm or greater, in general you could consider it a SVT and would treat it as a narrow complex tachycardia.

So in your post you said the r-r was regular so most likeky not a-fib plus you said the rate was 80 bpm thus that is not a fast enough rate for it to be a SVT. 220-age is usally a good guideline to follow.

hope this helped


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## Ridryder911 (Feb 24, 2009)

A-fib usually  has a regular/ irregularly pattern but does *NOT* always have to be. Second, you never heard of A-fib with RVR? What other rhythm do you have RVR with? Also it would not be RVR because it is not tachy and NO it is not a ventricular rhythm as it is called *ATRIAL * Fibrillation. 

If she did state what you described, she is ignorant. I welcome her to come on here and defend herself otherwise.


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## Macari (Feb 24, 2009)

yes it helped a lot. 
She said fast A-fib is anything above 60 because A-fib is a ventricular rhythm.  Right there I knew something was fishy.  

No, I never heard of A-fib with RVR, I even went back through my arrhythmia book and it wasn't in there. kinda made me mad.

This medic also shocked PEA 3 times the other day.
thanks


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## DT4EMS (Feb 24, 2009)

Macari said:


> yes it helped a lot.
> She said fast A-fib is anything above 60 because A-fib is a ventricular rhythm.  Right there I knew something was fishy.
> 
> No, I never heard of A-fib with RVR, I even went back through my arrhythmia book and it wasn't in there. kinda made me mad.
> ...




If these things are true...... please notify your supervisor. I am not so sure I would travel the medic bashing route until I knew the facts of a case. It is my hope there was just some mis-communication regarding the calls............. Not just blatant lack of knowledge on this medics behalf.  

A-fib by itself is not usually life threatening. 

Now the shocking PEA........... that is whole nother animal.


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## Ridryder911 (Feb 24, 2009)

DT4EMS said:


> If these things are true...... please notify your supervisor. I am not so sure I would travel the medic bashing route until I knew the facts of a case. It is my hope there was just some mis-communication regarding the calls............. Not just blatant lack of knowledge on this medics behalf.
> 
> A-fib by itself is not usually life threatening.
> 
> Now the shocking PEA........... that is whole nother animal.




The problem is; *IF * what was said is true the Paramedic does not appear to have a jest or concept of arrhythmia interpretation. A-fib is generally not usually life threatening but there is those exceptions and again representing one's knowledge base. 

R/r 911


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## DT4EMS (Feb 24, 2009)

Ridryder911 said:


> The problem is; *IF * what was said is true the Paramedic does not appear to have a jest or concept of arrhythmia interpretation. A-fib is generally not usually life threatening but there is those exceptions and again representing one's knowledge base.
> 
> R/r 911



I agree 100%. I would just be curious how this person could still be working if truly that clueless................


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## redcrossemt (Feb 24, 2009)

DT4EMS said:


> I agree 100%. I would just be curious how this person could still be working if truly that clueless................



Company and city has a lot to do with it, unfortunately.


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## Macari (Feb 24, 2009)

redcrossemt said:


> Company and city has a lot to do with it, unfortunately.



Exactly...


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## Aidey (Feb 24, 2009)

Maybe you should speak with your supervisor about this? Those are two pretty big mess ups in a short period of time.


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## eric2068 (Feb 25, 2009)

I think the A-fib with RVR issue has been solved, but I have a real problem with shocking PEA. This needs to be brought to the attention of your supervisor for QA/QI. The other problem I have is how did this person pass medic class, ACLS, and state boards (if that is how it is done your state). When I first got my EMT we used to shock asystole (no old jokes), but that was short lived (pun intended). Good Luck


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## maxwell (Mar 16, 2009)

This medic needs a coming to Jesus.  

Okay, AFib:
It can be regular, especially when it gets fast - but - even when slow, it can totally chill at 80 on the nose - but usually not for long periods of time.  All said and done, :excl:afib is usually irregularly irregular:excl:.  

It is NOT afib if you see a P wave.  Did you see a P wave?  
(plus never trust the monitor, always get a 12 lead!!!!!!!)  

And to make things more fun - NSR can be a little irregular.  Especially for patients who be breathing real deap!


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## Melbourne MICA (Mar 19, 2009)

*AFib*

The PEA issue is a bit too scary so I'll leave that one alone but the Afib deserves a bit more.

*Atrial* Fibrillation:

Eitiology:Results from firing of mutiple pacemaker sites in Atria. Not all impulses are conducted thru to ventricles so the palpated rate will always differ from the monitored rate. Afib is a common problem in the elderly and may go undiagnosed for years. Usually revealed when rate worsens causing symptoms or routine ECG scanning picks it up - such as by ambos!!!!

Characteristics: no regular monomorphic (coming from one pacemaker site) P wave attached to QRS, variable P-R interval, very irregular.
Rate: > 100 uncontrolled < 100 controlled - (not > 60/min) Technically when the rate is greater than 100/min and the QRS complex is within limits it is a member of the SVT family.

ECG appearance: typically "regularly irregular" - this is an age old description.
Maybe fast or slow - hence (old descriptor) "rapid or slow" Afib; new descriptor -  "Controlled or Uncontrolled Afib with rapid ventricular response" (RVR).

Note: Why "controlled" - this reflects whether the rate/rhythm is such that acute symptomology is minimised or prevented thru:

Rx: Acute episodes producing serious symptoms such as SOB, ischaemic chest pain  may be Rx with Amiodarone, Digoxin, beta Blockers or DC Reversion to sinus rhythm (hopefully) if episode paroxysysmal.

Aim of control: rate control or rhythm control to prevent symptoms and long term complications such as stroke resulting from thrombo- embolus. The Atria don't empty properly during systole so blood pools in the atria leading over time to thrombos formation - one breaks off and stroke can result. 

What pt meds will you see in the home? Anti coags such as Warfarin (Clopridogrel?) -  beta blockers, digoxin, amiodarone (new - not common yet mostly used in acute episodes) and others.

Ambos will see lots of pts in Afib when the rate gets out of control and the pt gets symptoms. Keep an eye out for it.

Hope this isn't too much.

MM


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## firemedic7982 (Apr 2, 2009)

This partner of yours brings up questions of their abilities as a medical practitioner. 

A-Fid RVR is an ATRIAL rythym. NOT Ventricular. 
I just consulted with my partner from work as I dont think you can have A-FIB RVR @ 60. She said she saw it one time years ago at somehwere around 90. 

However. A-Fib RVR can be SVT, but clearly not at 80. This is also not possible if the rythym is Regularly / Regular as you stated. 

The treatment needs to be of the underlying cause. Dehydration, hemo-dynamic instability, etc. 

Our protocols state Treating with fluids first. If the rythym is SUSTAINABLY above 130, treat first with cardizem. If it continues to increase, and is SUSTAINABLY irregular, consider cardioversion. 

As far as the Defib'ing PEA; I'm not touching that! :glare:


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## AnthonyM83 (Apr 2, 2009)

Was your partner confusing A-Fib for a complete heart block, thus thinking a rate of 60 would technically be a rapid ventricular rhythm?


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## Melbourne MICA (Apr 2, 2009)

*Rvr*

"RVR" is the arbitrary term of consensus now used to classify an AFib when its monitored rate gets over 100. Below a 100/min the term is not used. 

"Controlled and uncontrolled" describe whether the rate is routinely less or more than 100/min. Some people may get a run of acute Afib with arate over 100 say from too much coffee but not have a chronic problem. They have uncontrolled "Afib with a RVR". By the same token a chronic sufferer who gets an episode where the rate gets over 100/min also has uncontrolled Afib with a rapid ventricular response.

Whoever is saying she saw one years ago with a rate a 90 and called it RVR is getting terms mixed up. Ambos who use a monitor I would have thought would see Afib every week if not every shift.

Afib is rarely if ever regular - it can't be - There are multiple pacemaker sites firing randomly, though when fast it may *appear* to be - until you map it out. You can certainly see P wave in many Afibs but they will not be consistently attached to a QRS - this is the sinus node battling away in the background trying to get a word in to no avail.

AFib may be very wide and associated with aberancy - variations in the pathways through to the ventricles - such as if the pt has a pre-existing fascicular or bundle branch block. As it may be fast wide and seemingly regular (or apprently only mildly irregular) at first glance VT must be excluded by careful mapping and examination.

So it can look narrowish or wideish, fast or slow, have P waves or none but is characteristically irregular in appearance on monitor.

Afib is common and typically (relatively) benign. When the frequency of paroxysmal (or artificially induced) episodes increases with symptoms or the problem becomes chronic with symptoms docs will step in and Rx either. Rate control or reversion is the management choice. Dig, Ami, Beta Blockade and even Magnesium and Calcium Channel Blockers are drug Rx options being used. Cardioversion is also employed when the Afib becomes life threatening.

Afib can certainly be dangerous - in the long term it can lead to stroke, when "uncontrolled" ie the rate gets high (>100/min) it can produce ischaemic pain, SOB ( a common symptom for an ambulance call), pulmonary edema, hypotension and even cardiovacular collapse. If added to WPW with an accessory pathway it may also lead to VF - I saw that once years ago just as I had loaded the pt, driving off with a happy smiling family waving on the footpath.

As an arrhythmia whose origin is above the ventricles when the rate is > 100 it is an SVT.

Sorry I don't follow AnthonyM83's logic about the rate of 60 "technically being an RVR".

MM


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## Ms.Medic (Apr 4, 2009)

Maybe you should ask her to explain hersefl in front of a supervisor, that does 2 things, help a supervisor see what she's capable of without you running and "bashing her" or being the "bad guy" at the station. And,  he may be able to explain things a little better so that you would understand. If you havent went through a 3 lead/12 lead, or any other cardiology class/course these things can get kind of confusing if you dont know terms. Its very possible that you misinterpreted her, or just werent paying 100% attention because you didnt know the terms.


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## daughertyemta (Apr 4, 2009)

someone pull that medics cert.  geez..that is crazy.  Im know she's not the only one but damn..if you can't remember the rules for A-fib with RVR, you are ignorant!  WOW~~


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## Ms.Medic (Apr 5, 2009)

daughertyemta said:


> someone pull that medics cert.  geez..that is crazy.  Im know she's not the only one but damn..if you can't remember the rules for A-fib with RVR, you are ignorant!  WOW~~



I think that calling someone ignorant, and "pull their cert" is a little harsh when they arent on here to explain themselves. The OP is not trained in this and does not know the terms so its very possible that _*he*_ misinterpreted as well. 

I personally dont think that we should be on here bashing someone for doing or saying something that was not directly from them. The OP could have very easily just asked to clarify rvr and afib rather than all the other useless info about what she did or said. What good does that do for him or us ??? If theres a question about something, leave it at a question to be answered. If he wants to ask a question, just *ask the question*.


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