Atrial Fibrillation with RVR and Diltiazem

[Bieber]

Hey everyone,

So, right now, our protocols state that for stable patients with atrial fibrillation with rapid ventricular rate to administer diltiazem, reserving electrical cardioversion for patients who are unstable. Our new protocols, however, have withdrawn diltiazem from our formulary and only indicate treatment for unstable patients, but I'm having a little bit of trouble with this. It's probably just me, but in my mind I have always considered patients who are maintaining a good pressure "stable" even if they're symptomatic, but I think the AHA considers symptoms such as chest pain/dyspnea/etc signs of instability.

I guess my question is, would you consider a patient with an adequate blood pressure who is complaining of chest pain and is in atrial fibrillation with RVR stable or unstable? Would you cardiovert them or give diltiazem? What if you only had the option of cardioversion?

Thanks.

[Arctickat]

I'm just gonna post this link here so I don't have to edit the crap out of a cut and paste.

I consider chest pain to be unstable because the pain is likely caused by ischemia and time is muscle they say. I'd have cardioverted the guy in my story if he'd had pain.

Edited June 11, 2012 by Arctickat

[ERDoc]

Cardioversion should not be taken lightly, especially in a situation where you don't have proper meds to sedate. I would get the rate down with meds and fluids, if indicated and if that doesn't work, move to electricity. It's different from what AHA says, but it's the way I roll.

[Arctickat]

Oh, I don't take kicking my patient in the chest with a horse lightly at all, drugs are my preference as well. With an Afib RVR I'd like to try meds, but we have nothing but Adenosine, and we know how well that works in such a case. Cardioversion would have been my only option.

[ERDoc]

I didn't mean to imply that you were taking it lightly, I was just talking in more general terms. You can only use what is in your toolbox.

[Kiwiology]

For patients with tachydysrhythmia who are significantly compromised the treatment of choice should be cardioversion particularly if the rhythm is thought to VT

"Significant" is subjective but requires more than "a bit of chest tightness or SOB" - basically think patients who are cardiogenically shocked or going to end up that way, so the small, elderly or other patients with limited physiological reserve

Now sedation is a bit of a funny issue, in the hospital here the choice is midaz or propofol. In the pre hospital environment here we have midaz, fentanyl and ketamine. My personal preference is for IV midazolam and top it off with a bit of ketamine

Paramedic Officers can give some IV or IN fentanyl then cardiovert now, for years (like nearly twenty years) they could cardiovert but not give analgesia but my take on that is if you are that bloody crook you need cardioverthing you wont mind a bit of pain for some extra years of life

I do not think there is a role for prehospital blockers be they calcium, beta, sodium or otherwise; there may be a small role for beta blockers for MI patients but I am not familiar with the literature suggesting improved survival but I do believe some exists

[Bieber]

Cardioversion should not be taken lightly, especially in a situation where you don't have proper meds to sedate. I would get the rate down with meds and fluids, if indicated and if that doesn't work, move to electricity. It's different from what AHA says, but it's the way I roll.

I agree, although we will have adequate pain management and sedation available to us by standing order when our new protocols come out and they take diltiazem away (Versed, Ativan, fentanyl and morphine).

To everyone, with that in mind, would you consider ischemic chest pain sufficiently "unstable" to cardiovert in the absence of hemodynamic instability and without the option of diltiazem? What if the patient had been in atrial fibrillation for an unknown duration and wasn't currently anticoagulated?

Another thing I've considered (although we won't have it by standing order) is to call for amiodarone. Have you used it for atrial fibrillation before? Thoughts on its use for atrial fibrillation?

[Kiwiology]

A patient with AF shouldnt have ischaemic chest pain as the two have quite different etiologies, the exception perhaps is somebody with an anterior infarct affecting the atrial tissue sufficiently enough to develop ectopic foci

In the absence of haemodynamic compromise or VT I wouldn't cardiovert

Amiodarone for.AF is good stuff

[Bieber]

A patient with AF shouldnt have ischaemic chest pain as the two have quite different etiologies, the exception perhaps is somebody with an anterior infarct affecting the atrial tissue sufficiently enough to develop ectopic foci

In the absence of haemodynamic compromise or VT I wouldn't cardiovert

Amiodarone for.AF is good stuff

I'm talking about ischemia resulting from inadequate coronary artery perfusion pressure secondary to tachycardia (as opposed to coronary artery occlusion).

[Kiwiology]

Hmm maybe but it would have to be significant pain so probably not I am more interested in haemodynamic compromise