A-fib RVR and CHF

[Carlos Danger]

It isn't a typo or confusion, he's intentionally trolling

 

[Alan L Serve]

Either a typo or you just killed this patient.

Big typo. That's what I get for working a 72h shift. Yes, I definitely would have killed this patient. I meant to write give IV Diltiazem (a non-dihydropyridine) and not Amlodipine (a dihydropyridine). No I am not trolling, either.

 

[Carlos Danger]

Big typo. That's what I get for working a 72h shift. Yes, I definitely would have killed this patient. I meant to write give IV Diltiazem (a non-dihydropyridine) and not Amlodipine (a dihydropyridine). No I am not trolling, either.

So you know enough about the CCB's to know which classes these common ones belong to, yet you aren't aware that IV amlodipine doesn't exist? Interesting.

FWIW, amlodipine would not kill this patient. It wouldn't do anything at all to them. Assuming optimal absorption, it takes 6 hours just to start working, and close to 24 to reach full effect.

 

[Alan L Serve]

So you know enough about the CCB's to know which classes these common ones belong to, yet you aren't aware that IV amlodipine doesn't exist? Interesting.

FWIW, amlodipine would not kill this patient. It wouldn't do anything at all to them. Assuming optimal absorption, it takes 6 hours just to start working, and close to 24 to reach full effect.

IV Amlodipine doesn't exist? Interesting.

https://www.ncbi.nlm.nih.gov/pubmed/12021583

Effects of intravenous amlodipine on coronary hemodynamics in subjects with angiographically normal coronary arteries.

 

[Carlos Danger]

IV Amlodipine doesn't exist? Interesting.

No, outside of a research setting, it does not exist in the US.

Try finding some on formulary somewhere to give to someone in rapid AF and get back to me.

 

[Chimpie]

Thread cleaned up and reopened. Keep it on topic and civil.

 

[RocketMedic]

Talked with our senior clinical guy, he's OK with it but would personally go with a cardioversion in this particular case due to the preexisting heart damage. All's well that ends well though and he agreed that the rate needed fixing.

 

[VFlutter]

Talked with our senior clinical guy, he's OK with it but would personally go with a cardioversion in this particular case due to the preexisting heart damage. All's well that ends well though and he agreed that the rate needed fixing.

I have to disagree. Cardioverting this guy with a low EF and in A fib with unknown duration not on anticoagulation (more than just plavix) is a horrible idea. Especially since symptoms started days ago.

 

[RocketMedic]

I have to disagree. Cardioverting this guy with a low EF and in A fib with unknown duration not on anticoagulation (more than just plavix) is a horrible idea. Especially since symptoms started days ago.

Those were my thoughts as well.

 

[E tank]

I have to disagree. Cardioverting this guy with a low EF and in A fib with unknown duration not on anticoagulation (more than just plavix) is a horrible idea. Especially since symptoms started days ago.

Agreed.. I'd be pretty surprised if he formed was able to form thrombus on Plavix. The risk for thrombus formation in untreated a fib is about 5% a year (cumulative) and unless a large part of his heart were dead, even very low EF patients don't need thinners.

 

[MackTheKnife]

You mean he was on a beta blocker, the carvedilol. I wonder what the Plavix was all about? My first guess would be a coronary stent, but could have been for LV thrombus prophylaxis with such a low EF.

Sick dude.

Or the Plavix for the A-fib vice Coumadin.

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[VFlutter]

http://emedicine.medscape.com/article/2172597-overview#a1

 

[E tank]

Or the Plavix for the A-fib vice Coumadin.

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Very unusual for Plavix to be used for thrombus prophylaxis in afib. As far as his CHADS score goes, his risk is less than 6% yearly untreated, given what is given. Doesn't sound like chronic afib, though.

 

[VFlutter]

Agreed but even in a lower risk patient I would not be very agresssive trying to cardiovert prehospital unless that patient was crashing. Talking specifcally about new onset a fib with unknown duration without therapeutic anticoagulation. The standard of care is usually TEE prior to cardioversion and I think it's prudent to try chemical rate control and let it ride till the hospital.

 

[TomB]

In my opinion you should always start with NTG and CPAP with decompensated heart failure. The rate typically comes down on its own with increased SpO2 and decreased work of breathing. In fact this is one of the reasons we removed diltiazem from the trucks.

 

[RocketMedic]

In my opinion you should always start with NTG and CPAP with decompensated heart failure. The rate typically comes down on its own with increased SpO2 and decreased work of breathing. In fact this is one of the reasons we removed diltiazem from the trucks.

I take it that your agency cardioverts malignant tachydysrhythmias somewhat more often, then? I have found that nearly all of my diltiazem uses have been fairly clear-cut tachydysrhythmias (a-fib RVR and SVT refractory to adenosine); this was actually the first time I've given it in the context of a CHF exacerbation.

 

[TomB]

I take it that your agency cardioverts malignant tachydysrhythmias somewhat more often, then? I have found that nearly all of my diltiazem uses have been fairly clear-cut tachydysrhythmias (a-fib RVR and SVT refractory to adenosine); this was actually the first time I've given it in the context of a CHF exacerbation.

Shouldn't we all be cardioverting "malignant" tachydysrhythmias?

 

[Handsome Robb]

Shouldn't we all be cardioverting "malignant" tachydysrhythmias?

Depends on how you're defining "malignant".


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[VentMonkey]

Depends on how you're defining "malignant".

Not benign.

 

[RocketMedic]

Things that need fixin'