A flutter rate control

StCEMT

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Had what I highly suspect was a 2:1 flutter recently and wanted to get into the weeds on rate control and other bits since it's been a good long while since I've had a flutter patient.

Wanna get yalls experiences and opinions with the various routes and things to look for. Adenosine, Metoprolol, Amiodarone. Degrading to 1:1 after meds? If slow enough, do you sit on it to the hospital to ensure a possible thrombus doesn't get to take a trip? Other nuggets of wisdom? Let's hear what yall have got.
 

Tigger

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Diltiazem is my choice provided their pressure is adequate. Don’t think adenosine will be able to do anything about it and we don’t have beta blockers. I push 5mg at a time until I get some rate control, up till 25mg. Have been party one cardioversion with someone essentially unconscious and hypotension in 2:1, only took 50J just as advertised.
 
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StCEMT

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Diltiazem is my choice provided their pressure is adequate. Don’t think adenosine will be able to do anything about it and we don’t have beta blockers. I push 5mg at a time until I get some rate control, up till 25mg. Have been party one cardioversion with someone essentially unconscious and hypotension in 2:1, only took 50J just as advertised.
I haven't had dilt since my Missouri days. My 2 jobs now have metoprolol in the box, but no standing order for it. That's a med control thing for certain circumstances. And the adenosine is just diagnostic in this setting, but I've heard of it causing transition into 1:1 as well as some other meds. Not sure of the prevalence of that happening though since I've never seen or done that enough to have a good feel for.

For this person, pressure was sitting around 90-100 systolic. Their complaint was leg pain, they weren't at all bothered by their HR when sitting on the stretcher.
 

DrParasite

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I think the question might be, do you need to do anything? just because you can doesn't mean you always should.

Around here, diltiazem is the preferred choice, however there is also the concern of stable vs unstable.

with a complaint of leg pain, no issues with the HR, idk if anything would be indicated... if super unstable, cardiovert, if symptomatic, dilt, if stable, take them to the ER and let the cardiologists handle it
 
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StCEMT

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I think the question might be, do you need to do anything? just because you can doesn't mean you always should.

Around here, diltiazem is the preferred choice, however there is also the concern of stable vs unstable.

with a complaint of leg pain, no issues with the HR, idk if anything would be indicated... if super unstable, cardiovert, if symptomatic, dilt, if stable, take them to the ER and let the cardiologists handle it
Agreed, and we didn't. Not moving around seemed to make him more comfortable and the unfun symptoms go away. Moving is what made him feel not so great in the first place.

And there was issue with the HR. He was maintaining at 150ish and BP was on the lower end of what I'd allow. But his demeanor and complaint didn't reflect the HR at rest. He was the kind I sat there watching with the finger on the trigger the whole time, but nothing was immediately needed.

But it reminded me that it's been a good while since I've dug into a flutter specifically and any data behind it. Now that I have 35+ mile transports from some areas at one of my jobs, I'm trying to polish up how I play in those gray areas a bit.
 

Carlos Danger

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Cardizem is generally preferred unless decompensated HF is present. Esmolol and metoprolol can work. I would avoid amiodarone if they aren’t anticoagulated.
 

E tank

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Nothing wrong with giving a whack of fluid if the blood pressure is even a little saggy and unsymptomatic, all considerations of failure being considered, of course. Might even slow things down...
 

ffemt8978

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Nothing wrong with giving a whack of fluid if the blood pressure is even a little saggy and unsymptomatic, all considerations of failure being considered, of course. Might even slow things down...
*whack*

"Oww! Why did you hit me with the IV bag???"

"You're blood pressure was a little low."
 
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StCEMT

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Cardizem is generally preferred unless decompensated HF is present. Esmolol and metoprolol can work. I would avoid amiodarone if they aren’t anticoagulated.
Conveniently enough, this guy had JUST started eliquis. I think he had gotten it for about a week or so up to that point?
 

Carlos Danger

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Conveniently enough, this guy had JUST started eliquis. I think he had gotten it for about a week or so up to that point?
Had he recently started the Eliquis for the A-flutter, or for another reason? For some reason when I read your post I was envisioning a scenario where you discovered a previously undiagnosed flutter.
 
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Aprz

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StCEMT

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Had he recently started the Eliquis for the A-flutter, or for another reason? For some reason when I read your post I was envisioning a scenario where you discovered a previously undiagnosed flutter.
Clots in the leg. The flutter was new and unrelated to the Eliquis.
 

E tank

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So DVT and not arterial embolism it sounds like, yeah? That brings up a different set of questions...With a flutter (as opposed to a fib) there is a meaningfully reduced chance of left atrial appendage thrombus because the velocity of blood coming out of the appendage is sufficiently high enough to impede thrombus formation.

I'd definitely go CCI and/or BB before amiodarone in that scenario...not even sure it's approved by the FDA for a flutter anyway.....oh yeah...

and a whack of fluid, bit**es....
 
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StCEMT

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So DVT and not arterial embolism it sounds like, yeah? That brings up a different set of questions...With a flutter (as opposed to a fib) there is a meaningfully reduced chance of left atrial appendage thrombus because the velocity of blood coming out of the appendage is sufficiently high enough to impede thrombus formation.

I'd definitely go CCI and/or BB before amiodarone in that scenario...not even sure it's approved by the FDA for a flutter anyway.....oh yeah...

and a whack of fluid, bit**es....
Yea, BB is my first decent option that is available for stuff like this, I just have to ask for it as it's not actually written.

What are your thoughts on BB/CCI for folks with a pressure in the 90-100 systolic range? I'd expect some drop with Metoprolol, but I'd also expect a rise with a more appropriate HR. Metoprolol isn't something I see often, even in the ED when I bring someone in and hang around. I just don't have the exposure to it to have a good feel for it like I do other things.
 

E tank

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Yea, BB is my first decent option that is available for stuff like this, I just have to ask for it as it's not actually written.

What are your thoughts on BB/CCI for folks with a pressure in the 90-100 systolic range? I'd expect some drop with Metoprolol, but I'd also expect a rise with a more appropriate HR. Metoprolol isn't something I see often, even in the ED when I bring someone in and hang around. I just don't have the exposure to it to have a good feel for it like I do other things.
The MAP may or may not rise with a slower HR as that all depends on how full the heart/vascular beds are to begin with...should in theory rise with the rise in filling time but what actually happens...you get the point.

As to the BP question, if I was going to try and slow a patient down with that non-symptomatic pressure, it wouldn't be before I ran in a half liter of fluid (in the absence of failure..goes without saying). Might not have to slow him down after that and if I did, I'd hedge my bet against making the BP fall.

The little trick we have in the hospital is esmolol which is just an ultra short acting metoprolol. If that worked without any issues, sure, metoprolol could be a decent choice with or without CCB's.
 

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