Clue me in on AFib

[Old Tracker]

I'm a Basic. On the 15th we received a call for a 68 yo, F, at a local clinic with AFib. No chest pain, good RR, good SPO2, just weak. Clinic gave us a copy of her ECG print out. Print out showed a wide QRS complex with either negative T waves, in Lead II, or absent T waves.

Lady was released from the hospital yesterday. 0830 today, we go back to the residence and the lady is weak again. Hooked her up to the Zoll and this time she is tachycardic, up to a HR of 213, dropping down to the 140's-150's, then down to the 70's-80's and back up again. No chest pain, O2 sat, RA at 95% the whole time. The difference today was she had narrow QRS's on Lead II, and at times it looked like Sinus Tach, but would shift as the HR rose or fell, but no weird T waves. Any ideas what I was looking at?

Other history, high blood pressure and diabetes.

 

[VentMonkey]

Without a printout it sounds like A-Fib with an RVR (rapid ventricular rate) hence the jumps.

As long as she's stable it's a standard transport with O2, ECG, a 12-lead, a lock (judicious fluids aren't a terrible idea).

Cardizem, and/ or Amiodarone are typically the drugs of choice to treat chemically, if the patient remained refractory, and/ or unstable they'd probably go with cardioversion.

 

[NomadicMedic]

Here we use a beta blocker Afib with RVR.

I know, I know.

 

[Old Tracker]

She was stable, just weak. Was alert and oriented the whole trip, closed her eyes, now and then, but never did go to sleep. Thanks, I will research the RVR.

edit She also had some, imo, pretty serious pedal edema, which I originally linked to the diabetes, but am now thinking she wasn't getting very much return to her heart.

ALS intercepts for us can take awhile, so I am thankful she was stable.

 

[VentMonkey]

Here we use a beta blocker Afib with RVR.

I know, I know.

Here we can't even treat it in the field anymore, though unfortunately all we used was Verapamil. I'd had intermittent success with the ole Verapakill.

I've heard of beta blockers commonly being as a further-down-the-line treatment (and obviously, outpatient) for SVT's, so perhaps this is their thought process?

 

[NomadicMedic]

Nope. The pharmacy doesn't want to give us any meds that have to be kept in the fridge and they won't buy the powder that you add a diluent to... so effacy in rate control be damned, you get metoprolol.

 

[VFlutter]

She was stable, just weak. Was alert and oriented the whole trip, closed her eyes, now and then, but never did go to sleep. Thanks, I will research the RVR.

Also research Tachycardia-dependent or rate-dependent bundle branch block. It's common for people in A fib to have aberrant conduction as the rate changes.

 

[VentMonkey]

She was stable, just weak. Was alert and oriented the whole trip, closed her eyes, now and then, but never did go to sleep. Thanks, I will research the RVR.

I would (half) jokingly call it the most common arrhythmia you'll see as a paramedic to my interns.

It's common in the elderly. Simply put, the heart is a muscle and like all muscles as we age, it too weakens both inside, and out causing the propensity for such arrhythmias to occur.

 

[TXmed]

Here we can't even treat it in the field anymore, though unfortunately all we used was Verapamil. I'd had intermittent success with the ole Verapakill.

I've heard of beta blockers commonly being as a further-down-the-line treatment (and obviously, outpatient) for SVT's, so perhaps this is their thought process?

Ive heard mag has shown some promise in this area. Really this isnt a super common problem pre-hospital and alot of my experience dooing CCT is ER doctors treat it a little too agressive (often making the ventricular rate brady). Ive had success giving fluid bolus and re-assessing ETCO2 for symptomatic A-Fib

 

[zzyzx]

Sounds a bit like tachy-brady syndrome. I've only seen this twice, and it's pretty interesting to watch. Did she have P waves visible when her rate slowed?

 

[Nova1300]

She was stable, just weak. Was alert and oriented the whole trip, closed her eyes, now and then, but never did go to sleep. Thanks, I will research the RVR.

edit She also had some, imo, pretty serious pedal edema, which I originally linked to the diabetes, but am now thinking she wasn't getting very much return to her heart.

ALS intercepts for us can take awhile, so I am thankful she was stable.

A very important clue hidden in there.

This is what clinically symptomatic diastolic heart failure often looks like. Especially in a little old lady with longstanding diabetes and hypertension.

Recall that diastolic failure is not a failure of the pump, but a failure of the heart to relax in diastole. A stiff, remodeled ventricle does not fill well and by the time the valve closes, there is extra blood left behind in the atrium. Over time, this will lead to atrial volume overload and stretch, as well as the usual congestive-type symptoms.

Diastolic failure can affect either or both sides of the heart. Often, the left heart can compensate more vigorously and so you may not see the left-sided congestive symptoms.

But the right heart doesn't have that kind of capacity for compensation. It is not uncommon for these patients to present with gradual onset of right side congestive symptoms, specifically edema.

And, as that atrial overload worsens it will begin to cause atrial enlargement, stretch and remodeling. Pretty much a recipe for atrial fibrillation. And I bet her BNP would be elevated as well.

I don't make much of the changes in rate and morphology in the setting of clinical stability. New-onset a-fib is often a little jumpy at first, especially if the patient is converting in and out of the rhythm.

 

[StCEMT]

Here we can't even treat it in the field anymore, though unfortunately all we used was Verapamil. I'd had intermittent success with the ole Verapakill.

I've got cardizem at work, but still learning about it. Never was an option during medic school so I have zero experience with it. What are your thoughts on it?

 

[NomadicMedic]

I've got cardizem at work, but still learning about it. Never was an option during medic school so I have zero experience with it. What are your thoughts on it?

I'd always had good luck with cardizem, this is the first place I've not had it. My old medical director was pretty adamant about treating afib RVR in the field, so I used it pretty often.

 

[VentMonkey]

What are your thoughts on it?

I wish we had it, but, you know...California.

 

[StCEMT]

Hmm, good to know. Never had a need to us it yet, so it's one of our meds I have to go a bit further in maintaining. Honestly should probably find another crash course style article about it now that we are on the subject.

 

[Old Tracker]

I've got cardizem at work

Supposedly cardizem is contraindicated of the pt is on metoprolol, which was one of the 12 or so meds she was on. I just don't remember the whole list.

I want to thank you all for responding, I am learning more and more the more y'all add to the discussion. Like I said, I'm just a basic with not even a year on the job.

 

[Handsome Robb]

Supposedly cardizem is contraindicated of the pt is on metoprolol, which was one of the 12 or so meds she was on. I just don't remember the whole list.

I want to thank you all for responding, I am learning more and more the more y'all add to the discussion. Like I said, I'm just a basic with not even a year on the job.

It's contraindicated if they've had IV beta blockers within an hour or two, not if they're on oral beta blockers.

Cardizem works well in my experience.


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[E tank]

It's contraindicated if they've had IV beta blockers within an hour or two, not if they're on oral beta blockers.

Cardizem works well in my experience.


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Depends on the b blocker, I'd guess. I wouldn't hold it if I thought it would be useful...but in my practice, I go amiodarone before Cardizem anyway.

 

[Old Tracker]

It's contraindicated if they've had IV beta blockers within an hour or two, not if they're on oral beta blockers.

Cardizem works well in my experience.

Not contradicting you by any means. Just mentioning what I read, now you've added to more tidbits to my knowledge about the IV beta blockers or the oral ones.

 

[Carlos Danger]

Beta blockers are more of a precaution than a contraindication. Clearly you have to be really careful slamming someone with 10 of lopressor and then a few minutes later, 20 of cardizem. Like someone said, it also depends on which one you are talking about. Esmolol, for instance, is completely out of your system 10 minutes after it is injected.