Defibrillating A-FIb

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I worked as a paramedic for one company for 2 years, them moved and joined another and they have very differing opinions of Rx for A-Fib. One says that you use diltiazem and vagal to Rx an you do not defibrillate cuz of risk for heart attack and stroke are so high, my new job says that it is the definitive Rx for symptomatic A-Fib. Wanna know what others think.
 
I had this misfortune of going through two P classes because of my registry problems. The first class was the older train of thought which you have mentioned. The new class we were trained pretty much in class that the blood pressure and mental status decide if you go drugs or eletrical.90 systolic being a good measure. Below we are taught to treat with electrical and above try drugs first. Our protocols also state this. My Paramedic Preceptor is an old hand with almost 20 years and told me to try drugs first and then electrical if you need. Just my 2 cents and not a guidebook.
CHeck out my post on Diltiazem with AFib RVR .http://emtlife.com/showthread.php?t=13340
 
Is it new onset A-fib or has it been a long-term problem? You run the risk of cardioverting (I wouldn't defibrillate a perfusing rhythm) the heart into a normal rhythm and breaking clots loose that form in the atria, especially in someone that has A-fib as their "normal" rhythm. If it's new onset A-fib (less than 48 hours), electrical therapy is indicated...but only in symptomatic patients. I wouldn't be cardioverting all A-fib's you run into.
 
You definitely need to determine if it is acute vs chronic. There are a lot of people that A-Fib is their normal rhythm. If it is an acute episode then you decide if the patient is stable or unstable. Stable patients do least invasive first and decide with medical control how far you want to go. You will want to cardiovert unstable patients (consider sedation if time allows).
 
I actually had a call very much like this last week and we were discussing it today.

If the patient is unstable because of the tachycardia, the treatment of choice is synchronized cardioversion. However, if the patient has been in atrial fibrillation for over ~48 hours without adequate anti-coagulation, you risk them throwing a clot which could cause a stroke, heart attack, PE, or embolism somewhere else.

That being said, my patient was on aspirin and coumadin for years, and reported being compliant with it. I contacted medical control, explained to them the situation (including coumadin dosing and compliance) and the physician authorized cardioversion. It fixed the guy and we transported a much better looking and feeling patient to the hospital without further incident. I asked an attending physician about the call when we arrived, and he reported that they regularly cardioverted patients with a-fib, as long as they were adequately coagulated (demonstrated by clinical history or labs).

So, if your patient has new onset a-fib with RVR, or is adequately coagulated, cardioversion isn't as awful as some make it seem. At least according to two physicians last week.

If there's any question about coagulatory (?) status, such as an inadequate history, or onset time; I would be very careful and try your medications first (calcium channel blockers). Even in your unstable patients, Cardizem and similiar can work very quickly and have little risk compared to cardioversion.

I'm interested to hear if there are other thoughts on this because I was always "scared" away from cardioversion for these patients in medic school...
 
I have always heard the same regarding acute v chronic, my question to the more seasoned medics is what is the best way of determing acute v chronic? Med Hx? Complaints? etc...
 
redcrossemt said:
I actually had a call very much like this last week and we were discussing it today.

If the patient is unstable because of the tachycardia, the treatment of choice is synchronized cardioversion. However, if the patient has been in atrial fibrillation for over ~48 hours without adequate anti-coagulation, you risk them throwing a clot which could cause a stroke, heart attack, PE, or embolism somewhere else.

That being said, my patient was on aspirin and coumadin for years, and reported being compliant with it. I contacted medical control, explained to them the situation (including coumadin dosing and compliance) and the physician authorized cardioversion. It fixed the guy and we transported a much better looking and feeling patient to the hospital without further incident. I asked an attending physician about the call when we arrived, and he reported that they regularly cardioverted patients with a-fib, as long as they were adequately coagulated (demonstrated by clinical history or labs).

So, if your patient has new onset a-fib with RVR, or is adequately coagulated, cardioversion isn't as awful as some make it seem. At least according to two physicians last week.

If there's any question about coagulatory (?) status, such as an inadequate history, or onset time; I would be very careful and try your medications first (calcium channel blockers). Even in your unstable patients, Cardizem and similiar can work very quickly and have little risk compared to cardioversion.

I'm interested to hear if there are other thoughts on this because I was always "scared" away from cardioversion for these patients in medic school...
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How can you definitively ascertain coagulation status???? Are you running a PT and INR with your on board I-Stat?

Rule #1, Pts LIE!!!!!!!!!!!!! On a regular basis!!!!!

Using assumed coagulation status is walking a fine line. Instead, you need to define if they are hemodynamically compromised. That you can directly and objectively identify. If they are, then cardioversion would be appropriate. If not, then medicinal therapy is appropriate (with cardioversion as a backup if it fails to resolve). Its pretty standard reasoning, even the AHA thinks so........................

BTW - Do you routinely have to call medical control for cardioversion?
 
Just another piece of food for though. How long you are going to have this patient may also play in. 5 minutes to the ER ? Its a judgement call. Flight LP has a good point too. The area I work in has a lot of under educated folks. They may not be trying to lie to you but sometimes I get the reply I have the "high blood" Meaning either sugar or pressure. "Space makers" also exist. Look at thier meds and see if they have been dosing on the anti coags and report your findings to support your actions to online med control. But again I would use the pressure and mental status to determine what to do with the patient.
 
In my 32+ years as a Paramedic I truthfully say I only cardioverted 1 A-fib in the field. Alike Flight described, the patient was decompensating and was hemodynamically unstable.

I have cardioverted literally hundreds in the ICU/CCU setting though. Many that would not respond to Dig or Cardizem therapy and after a period of time we could see would not pharmacological convert the cardiologist would ask for cardioversion.

Again, treat the patient not the monitor.

R/r 911
 
Just making sure I wasn't TOTALLY out of the conversation at hand, thanks ^_^
 
Flight-LP said:
How can you definitively ascertain coagulation status???? Are you running a PT and INR with your on board I-Stat?
Click to expand...

I wish I had an iStat... but I don't. And yes, patients do lie, whether purposely or due to misunderstandings.

Flight-LP said:
BTW - Do you routinely have to call medical control for cardioversion?
Click to expand...

Cardioversion is pre-radio for us. I contacted because, as I said before, I've been scared away from cardioverting a-fib due to risk of embolus, and wanted expert opinion on whether I should try medication or go right to cardioversion.

So, I guess I should just cardiovert any unstable a-fib without trying cardizem first? Is there not really a risk of throwing a clot?
 
"defibrillating" A-Fib should be broken down into two categories...stable vs. unstable. (And please, dear baby Jesus, don't say defibrillate, say cardiovert. I know it's a trivial matter of sematics, but, it makes me nervous)

-SICK: Cardiovert them. With electricity. Nobody will *ever* fault you for cardioverting if you sincerely felt they looked BAD. If they have a mural clot, well, you gotta be alive to suffer the consequences, fellas!

-NOT SO SICK: this should be broken down into people who have had it for < or > 48 hours.
(+) Less than 48 hrs: try to convert to something that aint afib. Ibutilide. Amiodarone. Dofetilide.
(+) MORE than 48 hrs: the name of the game here is rate control. Use metoprolol. I hate using CCBs (but if I have to I'll use 5mg dilt x 4 PRN --> gtt at 5mg/hr if their pressure doesn't suck). {at least we're not using verapakill anymore, sh*t...}.

Most of the time, in the field, you dunno if they've had the afib since breakfast today, or since the dinos. So, if in doubt, rate control if symptomatic.
 
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maxwell said:
...don't say defibrillate, say cardiovert. I know it's a trivial matter of sematics, but, it makes me nervous
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It really isn't a matter of semantics. Maybe on a forum one doesn't really think of the difference, and most of us probably do know what the OP means, but there are medics out there who don't know the difference.
 
redcrossemt said:
So, if your patient has new onset a-fib with RVR, or is adequately coagulated, cardioversion isn't as awful as some make it seem. At least according to two physicians last week.

If there's any question about coagulatory (?) status, such as an inadequate history, or onset time; I would be very careful and try your medications first (calcium channel blockers). Even in your unstable patients, Cardizem and similiar can work very quickly and have little risk compared to cardioversion.
Click to expand...

This is how I was taught too. However, calcium channel blockers do have very real risks such as dropping a pt's blood pressure on the floor very very quickly. It's one of the risks that must be weighed when treating a pt. I will say that most pts have no idea what the coagulation (? coagulatory ?) status is and it's risky to cardiovert a pt with chronic A-fib. Coags can and do change from the time they are drawn until the results are given. Usually pts at home or in nursing homes (that we would pick up) had their levels drawn days previously, so if they happen to know, they may have old info.
 
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maxwell said:
{at least we're not using verapakill anymore, sh*t...}.

QUOTE]

That's all we have in the CCB category. I can't even tell you the last time someone used it. It's not a standing order and the docs won't let you use it since our transport times are almost always less than 15 minutes. We just recently got metoprolol added to the box.
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Afib and sync-cardioversion

I agree with a few of the guys about sync-cardoverting Afib. Whilst a rare necessity it is not out of the question in pre-hospital. I've personnaly seen Afib degenerate into Vfib in a pt with pre-existing cardiac disease who decompensated rapidly in our truck with the family waving goodbye on the footpath!!!!

I don't know if he had any pre-existing WPW or accessory pathway issues. I was non MICA at that point but I know for sure had it been today I would have synced this man immediately. Any wide complex Afib should raise an eyebrow or two.

Any pt haemodynamically decomensating in the setting of cardiac tachy arrhythmia is in strife and needs immediate measures to improve myocardial perfusion and/or arrhythmia reversion depending on the cause.

I definately agree with Murpharino on the issue of "Semantics". Defib is certainly not the same as synchronised cardio version and I would be concerned if any of the EMT-P's out there thought it was the same. Seeing that little red dot above all the R waves is a must if you're going to call it syncing.


Just a quick note on Verapamil. We poor shmucks down under still use it though not very often these days. I've given it a number of times with good effect but it certainly trashes BP so you give it oh so slowly!

Typically I will trickle in a bit check the monitor, then give a bit more till the rate drops and/or the rhythm reverts and symptoms subside. I have rarely had to give the required full dose in the guideline. If we get a big BP drop we go with aramine so the situation often ends up being a juggle with aramine and verapamil. The beta blockers some of you carry (or the pt has) would of course be a big no no for us to start the big V. Nasty drug. Still it makes life interesting.

MM
 
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