How do you treat this.

[NomadicMedic]

Curious about your plan.


Patient Information:
- Age: 70-year-old male
- Symptoms: 8/10 chest pressure, slight dyspnea on exertion
- History: 2 stents (1 year ago), prostate cancer, hyperlipedemia
- Medications: Plavix, Lipitor, Flomax
- Allergy: Penicillin
- Weight: 77 kg

Clinical Findings:
- Monitor: AFib with RVR, rate variable from 120 to 170
- Blood Pressure: 124/82
- Lungs: Clear bilaterally
- Interventions: Took 2 NTG with no relief. 324 of ASA by BLS crew. 18g IV with NSS.

20 minute transport time. What do you do for him?

 

[PotatoMedic]

Fentanyl (70mcg), dilt (10mg (my local protocol is just 10)), and a little bit of oxygen.

I'd also want a 12 lead before dilt and a second if anything changed.

Fentanyl is technically optional.

 

[DesertMedic66]

I would first try to determine if the A-Fib RVR is an actual rate issue or if the A-Fib RVR is trying to compensate for something (hypovolemia, sepsis/infection, dehydration, etc.

I would get a 12-lead. I may try a 250mL LR bolus to see if there are any changes. If not then 19.25mg Dilt. Repeat dosage at 25mg. I can move on to an infusion or switch to a beta blocker or as a last option Amio.

Technically I think someone could justify cardioversion depending on their protocol. For example my guidelines say if the patient is unstable, one of the definitions for unstable is severe chest pain, then sync cardioversion can be indicated.

 

[NomadicMedic]

I’m specifically curious about what YOU would do. Not a maybe or I’d consider… what will YOU do during this patient contact. This isn’t a unicorn case, this is a pretty common call. A bread and butter paramedic run.

 

[FiremanMike]

if I had dilt, I’d use it. If not, I’d sedate and cardiovert.

 

[E tank]

....or as a last option Amio.

Volume and rate control....I'd be reticent for DCCV 'cause we don't know how long he's been in a fib and the risk of thromboembolism with conversion. Prolly avoid amiodarone for the same reason.

 

[Tigger]

If a 12 lead has not been obtained, that would be first.

Assuming nothing is pointing towards a latent infection or volume loss, I’d hang some fluids and give some fentanyl. If a 250 NS challenge has no effect on the rate, I would give diltiazem. I’d continue the fluids. If the diltiazem was not successful, I’d redose.

I am not leaning towards cardioversion, this patient does not sound acutely unstable to me.

 

[MMiz]

I'm not a Paramedic, so I asked AI. Here is what it suggested:

Initial Assessment:

1. Monitor Vital Sign
2. Get 12 Lead ECG

Immediate Interventions:

1. Oxygen Therapy: Administer oxygen to maintain an oxygen saturation above 94%.

Manage A Fib:

1. One of the following:
   1. Diltiazem: Administer 0.25 mg/kg IV over 2 minutes. If there is no response, a second dose of 0.35 mg/kg IV over 2 minutes may be given after 15 minutes.
   2. Metoprolol: Administer 5 mg IV every 5 minutes, up to 15 mg.
   3. Amiodarone: Administer 150 mg IV over 10 minutes if other medications are contraindicated or ineffective.

Managing Pain:

1. If chest pain persists, consider administering morphine sulfate (2-4 mg IV) for pain management, provided there are no contraindications.

Fluids:

1. Maintain IV fluids

How did I, I mean it, do?

 

[CCCSD]

I'm not a Paramedic, so I asked AI. Here is what it suggested:

Initial Assessment:

1. Monitor Vital Sign
2. Get 12 Lead ECG

Immediate Interventions:

1. Oxygen Therapy: Administer oxygen to maintain an oxygen saturation above 94%.

Manage A Fib:

1. One of the following:
   1. Diltiazem: Administer 0.25 mg/kg IV over 2 minutes. If there is no response, a second dose of 0.35 mg/kg IV over 2 minutes may be given after 15 minutes.
   2. Metoprolol: Administer 5 mg IV every 5 minutes, up to 15 mg.
   3. Amiodarone: Administer 150 mg IV over 10 minutes if other medications are contraindicated or ineffective.

Managing Pain:

1. If chest pain persists, consider administering morphine sulfate (2-4 mg IV) for pain management, provided there are no contraindications.

Fluids:

1. Maintain IV fluids

How did I, I mean it, do?

Missed one BIG thing:

Wallet Biopsy. First and Foremost.

 

[Akulahawk]

I’m specifically curious about what YOU would do. Not a maybe or I’d consider… what will YOU do during this patient contact. This isn’t a unicorn case, this is a pretty common call. A bread and butter paramedic run.

For a patient that's relatively stable and basically ONLY in AFib/RVR, how I would treat would be a 250 mL fluid bolus, maybe extend that to 500 mL if I think the patient is very dry. Then my next choice is more about what I have available. If I have Diltiazem or Metoprolol, I'd give a dose of whatever I have and redose in 10-15 minutes if rate control is not achieved. Given a choice of BOTH, I'd probably choose diltiazem, especially if I have a lot of it, is that I can start a drip to maintain even a somewhat controlled rate.

If I know when that arrythmia began, then I can also begin to explore conversion options but if I don't know, I'm going to stick with rate control.

The above is, of course, after getting a 12-lead, basic vitals, and the like, such that I'm relatively certain that the problem is AFib/RVR and not some underlying other concern like infection or volume loss. I might also consider the possibility of stimulant usage but I'm still going to deal with rate / volume concerns first.

 

[CALEMT]

So assuming the 12 lead shows AFib RVR, I would give a 250 bolus PRN. Emphasis on PRN, the pressure is great considering the wide range of heart rate. I would treat the CP as stated in the OP and consider fentanyl if it doesn't subside. What I have available to me as options for the AFib is limited. For me its a base hospital order and not a standing order, but I have the option of Amiodarine (150mg) and Lidocaine (1mg/kg). I know synchronized cardio version has been discussed in this thread, technically I could justify it but I don't really see a need to. Sure the pt has CP, but overall is hemodynamically stable. I didn't see skin signs, but I would assume they're normal?

 

[ChrisMed1]

EMT not a medic but out of curiosity at a rate of 170 how can you tell Afib with RVR vs A flutter? I'm just curious because a recent call I rode on the medic unit just helping out and the medic told me to watch this and it was a PT with Afib that was having moments of Aflutter and when the rate got really fast it looked really hard to see the defining features like P waves vs T waves just because the rate, anyway just a chance for me to ask a question.

My treatment if this was a pt of mine would just be transport, aspirin, nitroglycerin and depending on hospital ETA may get ALS on board

 

[FiremanMike]

EMT not a medic but out of curiosity at a rate of 170 how can you tell Afib with RVR vs A flutter? I'm just curious because a recent call I rode on the medic unit just helping out and the medic told me to watch this and it was a PT with Afib that was having moments of Aflutter and when the rate got really fast it looked really hard to see the defining features like P waves vs T waves just because the rate, anyway just a chance for me to ask a question.

My treatment if this was a pt of mine would just be transport, aspirin, nitroglycerin and depending on hospital ETA may get ALS on board

Irregularly irregular, you can still see it at 170, but especially with the wide swing of heart rate as described in the OP, you’d definitely see it.

 

[DrParasite]

I know synchronized cardio version has been discussed in this thread, technically I could justify it but I don't really see a need to. Sure the pt has CP, but overall is hemodynamically stable. I didn't see skin signs, but I would assume they're normal?

That was my question as well... is the patient considered to be so unstable that we are cardioverting in the field? more importantly, should we? BP is good, HR is a little wonky, but that happens with AFIB w RVR. I think we used to give Dilt for this, but even so, is the patient so unstable? is this something that can wait until a cardiologist takes a look?

While I support doing stuff in the field when it is clinically indicated, in this case, maybe we should manage the symptoms and ask for the cardiologist to meet us in the ER for a second opinion?

 

[Tigger]

Rate control is a great way to provide symptoms relief. I suspect this patient will feel much better post CCB, which is a big reason why I give them.

 

[FiremanMike]

That was my question as well... is the patient considered to be so unstable that we are cardioverting in the field? more importantly, should we? BP is good, HR is a little wonky, but that happens with AFIB w RVR. I think we used to give Dilt for this, but even so, is the patient so unstable? is this something that can wait until a cardiologist takes a look?

While I support doing stuff in the field when it is clinically indicated, in this case, maybe we should manage the symptoms and ask for the cardiologist to meet us in the ER for a second opinion?

After having worked in the ED for awhile, I don’t find cardioversion to be the extreme treatment that I once did. I would certainly prefer having some cardizem but we just don’t have it here right now.

Of course there’s so much more to this case that we don’t have. Are we presuming prior history of a-fib d/t plavix? Are they compliant with plavix? Are they compliant with BP meds (I.e. is the listed pressure actually on the low side for this patient). How does the patient actually look..

 

[E tank]

After having worked in the ED for awhile, I don’t find cardioversion to be the extreme treatment that I once did. I would certainly prefer having some cardizem but we just don’t have it here right now.

Of course there’s so much more to this case that we don’t have. Are we presuming prior history of a-fib d/t plavix? Are they compliant with plavix? Are they compliant with BP meds (I.e. is the listed pressure actually on the low side for this patient). How does the patient actually look..

Anti-thromboembolism prophylaxis in afib with plavix is pretty unusual. I don't think I've ever seen it and if I have it was a one off or a long time ago. If someone is on it, it's likely for the other usual reasons. This scenario has stents in the hx so that's the reason I'd attribute to the plavix. Most folks don't trust it and will get an echo cardiogram to rule out left atrial thrombus for elective DCCV. Either coumadin, or more often now, a Xa inhibitor or sometimes a direct thrombin inhibitor are way more likely. If this were real life, I'd say the afib was a new finding and be real careful moving forward.

 

[FiremanMike]

Anti-thromboembolism prophylaxis in afib with plavix is pretty unusual. I don't think I've ever seen it and if I have it was a one off or a long time ago. If someone is on it, it's likely for the other usual reasons. This scenario has stents in the hx so that's the reason I'd attribute to the plavix. Most folks don't trust it and will get an echo cardiogram to rule out left atrial thrombus for elective DCCV. Either coumadin, or more often now, a Xa inhibitor or sometimes a direct thrombin inhibitor are way more likely. If this were real life, I'd say the afib was a new finding and be real careful moving forward.

That’s a fair point, that said there was a transition between Coumadin and xaralto/eliquis during which I’m pretty sure everyone was put on plavix for everything..