Atrial Fib w/ RVR

18G

18G

Paramedic
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Had this patient today:

80 y/o male. Admitted four days ago with COPD exacerbation and pneumonia. Being treated with IV antibiotics rocephin and zithromax. Nurse report's pt. doing pretty well yesterday, no acute distress.

This morning at 0700, nurse notices change in pt. status. Pt. has history of atrial fib and heart rate increases - AF w/ RVR in 170's with RBBB (RBBB reported to be old). At very beginning of RVR pt. was reported to have a BP of 208/100, was pale, dyspneic, and not looking well. Profound pulmonary edema was present with diminished sounds on the right (right sided infiltrate/pneumonia noted and has been baseline since admission), no JVD, pedal or other edema. Pt. is afebrile, wet sounding cough, no chills. No active chest pain or anginal equivalents. Mental status is normal - not altered. Resp rate maintained at 28, mildly labored, SpO2: 100%(15lpm). Baseline was 93% on 2lpm prior to this event. Nurse reported BNP to be elevated yesterday at like 950. No cardiac enzymes available.

12-lead was acquired and physician onscene said she suspected an MI because of ST changes. The print out said consider acute MI which I believe is what she went off of. I didn't see any ST changes or indication of MI. I acquired multiple 12-leads during transfer and none showed ST changes although last one acquired showed some T-wave inversion in V3 and V4.

I arrived and received report that pt. was bolused with diltiazem, received 20mg of Lasix, 1mg of Morphine, and was started on a diltiazem drip at 10mg/hr. Just prior to transfer pt. was started on heparin as well and given another 20mg of Lasix.

Enroute pt. remained current status - no chest pain or change in breathing. I did note a trend with decreasing BP. Initial was 115/60 and trended down to SBP of 98-96 and went as low as 88/54. BP repeated to confirm and diltiazem decreased to 7mg/hr which maintained BP right around 100. Pt. does have history of low-end BP with a BP yesterday of 102/58.

Questions / Discussion:
1) CPAP - due to the profound pulmonary edema and initial pressure reported at 208/100 and increased BNP as of yesterday I was thinking CHF and that pt. may benefit from CPAP. I mentioned it to the nurse but wasn't ordered. With pressure being on low-end with the diltiazem I did have some concern over what the CPAP may have done to the pressure and was okay with the 100% SpO2, normal mentation, and only mild resp distress which pt. rated as a 2/10. Thoughts???

2) Primary problem? My thinking is the pt. had, for whatever reason, the RVR which decreased ventricular filling, created an inefficient pump and resulted in pulmonary edema. Pt. did have some crackles from the pneumonia but no where near as significant as today with this episode.

When the rate was reduced the pt still had the fluid in the lungs and the diltiazem decreased cardiac output and heart wasn't able to move the volume like it should. Hence, remaining with pulmonary edema. And I believe a component of CHF was present.

Should the diltiazem drip been maintained as ordered?

3) What is your impression of what was going on?
 
I agree with what your thinking for the primary problem. Did pts HR decrease with the diltiazem? If sats stayed that hi and he really wasnt complaining of much SOB I probably wouldnt have gone with CPAP
 
I think its difficult to differentiate between dyspnea secondary to pneumonia vs the same secondary to acute pulmonary edema.

Impression is similar to yours, I think I'd hold off on CPAP for the time being, but it may not hurt. Pressure is somewhat borderline and youve recognized the pt has a pump/rate issue, so the increased intrathoracic pressure may not help those issues...
 
Curious about the heart rate after all this. Sounds like your right on the $$$ with this patient. HTN and crackles make me look for a bottle of nitro spray usually. I tend to go with nitro vs. lasix if I am at all suspicious about pneumonia. Nice thing about CPAP is you can turn it off if it ain't working the way you want it to.

If this guy is a COPD'r 100% O2 sats, might need to O's turned down?
 
Rate was controlled well with the diltiazem.. maintained 85-100. Pt. had maybe 2 or 3 episodes of 130's lasting <15sec.

Actually I did titrate the oxygen down. The staff had pt. on 15lpm. I turned it down to 10lpm and maintained at 97%. Im not a big fan of indiscriminate use of oxygen.

Appreciate the input so far.
 
Is the afib with RVR due to hypoxic stress from the heart failure, or is it a diastolic heart failure due to rate? We'll never know...

I would have treated the initial presentation as CHF. Afib w/RVR usually isn't something that gets me excited about till the rates get to around 200. The dyspnea might have very well resolved by getting the preload off.
 
Thoughts:

First- form a DDx: Is this an exacerbation of his COPD or is this a manifestation of worsening CHF? If so, what's causing them? Does he have worsening CHF because he's in A. fib with decreased ventricular filling which leads to a decreased cardiac output and thus has fluid backing up into his lungs? Or better yet- is this A. fib just distracting and what he really has is an acute CHF exacerbation secondary to an MI?

Pulmonary edema in itself is not a diagnosis- it's secondary to something.

What is the worst case scenario and what would be the most catastrophic to let go? My vote, and apparently the attending's as well, is that this patient could very well be having an MI. You don't need ST-elevation on a 12-lead to be having an MI. Furthermore, I'm not willing to dismiss that the MD may very well have seen ST-elevation- you only need 1 mm of elevation. Potential reciprocal changes are even more foreboding (for posterior wall infarct) and are pretty highly sensitive for MI.

Any JVD or abdominal distension in this patient? What about peripheral edema?

I agree with you that a couple of things would have been nice here. First, cardiac enzymes- will help in differentiating MI. In this patient, there's a good chance he always has a high BNP. Second, CXR- PA and lateral. Third, ABG- differentiation with COPD. Pulmonary function test might not even be that bad of an idea. Also, a CBC with metabolic panel should accompany any of these patients. This is also where a patient's medical records come in handy for comparison.

As for the decreasing blood pressure- not concerned, assuming no change in patient mental status. That brings us to treatment: Indeed, part of my goal would be to actually drop his blood pressure a little in an effort to decrease afterload. Also he is being diuresed. What I particularly like about the diltiazem is that we can kill multiple birds with one stone. Being a Ca++-blocker, we have vasodilation which decreases our afterload and we also have strong AV node conduction slowing- good for a patient who sounds like he has A. fib with rapid ventricular capture => reduced myocardial O2 demand. In short, I'd keep him on the diltiazem. Lasix for the pulmonary edema (also why it's nice to have the metabolic panel).

As for the CPAP- sure, you could; I would prefer biPAP, but you use what you have. He has a disease known to respond to CPAP. This is where the ABG would have been nice- hypercapnic acidosis (PaCO2 >45 mmHg or pH <7.30). As you said though, he wasn't really having that much difficulty breathing, mental status sounds like it was fine, and his pulse ox was saturated. Do I think it was detrimental to his care to not receive it? Nah.

Did the patient improve from before treatment to after?

-Medicus
 
Patient did not improve much from what was initially reported to me by the nurse except heart rate decreased. While an improvement, the patient was still in moderate resp distress and with a good deal of pulmonary edema.
 
SpO2: 100%(15lpm). Baseline was 93% on 2lpm prior to this event. Nurse reported BNP to be elevated yesterday at like 950
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Put him back on the nasal cannula.
 
I didn't put him back on a N/C but did decrease the FiO2 to 10lpm which maintained a sat of 95%.
 
Hmmmmmmmmmm, sounds like a thinker. Wet lung sounds with an increased BNP? And a history of CHF, I do believe after you dialed back his Card. Drip i would have placed him on CPAP, I do not see this guy getting better much quicker unless his pulmonary Edema is being controlled aswell. I understand the threat of increased intra-thoracic pressure from CPAP, but CPAP having an effect on his BP is a maybe, and if it does you can take the CPAP off or always dial the Dilt back even further aslong as what you have just dialed it back to is still controlling the rate. Does he have a history of Afib? I understand your concerns with the high level of o2 for a COPD pt. but that whole throwing off the Co2 Drive/hyperoxemia really does take quite a while, and wont happen while you have this pt. unless you are going long distance.
 
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Judging by the wet lungs & pulmonary edema, sounds like CHF.

Diltiazem sounds like they were looking to lower the BP and take care of the Afib...

The v3/v4 T wave inversion sounds like an septal wall MI, but It could be related to medications possibly.

Thats what I got so far.
 
DV_EMT said:
Judging by the wet lungs & pulmonary edema, sounds like CHF.

Diltiazem sounds like they were looking to lower the BP and take care of the Afib...

The v3/v4 T wave inversion sounds like an septal wall MI, but It could be related to medications possibly.

Thats what I got so far.
Click to expand...

Septal Wall MIs are so rare though I wouldn't bet my paycheck on it. The time you see a True and isolated Septal wall MI is the same time you might think about asking that hot girl out on a date that lives on the same floor as you. It is your lucky day!
 
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Following the Dilt, 18g wrote
Patient did not improve much from what was initially reported to me by the nurse except heart rate decreased. While an improvement, the patient was still in moderate resp distress and with a good deal of pulmonary edema.
Click to expand...

Sound like that was a perfect opportunity for CPAP. It's use in EMS was designed for these patients. Not putting CPAP on this patient, in my system, would result in getting your chart dinged in QI for not meeting the standard of care.
 
Fish said:
The time you see a True and isolated Septal wall MI is the same time you might think about asking that hot girl out on a date that lives on the same floor as you. It is your lucky day!
Click to expand...


But I'm married ^_^
 
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