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On ‎5‎/‎27‎/‎2017 at 7:34 PM, Spock said:

I can think of any number of drugs to give this patient and none of them include NTG or ASA.  ERDoc is certainly correct in that this is rate related and with the a SBP of 110, the patient leans toward stable rather than unstable although that may not be the case for very long.  Diltiazem is the drug of choice here followed by beta blockers, amiodarone, and perhaps verapamil.  My service carries diltiazem and amiodarone but not beta blockers or verapamil.  I wish we carried a beta blocker such as esmolol, lopressor, or labatelol.  

The last patient I had go into AFIB with RVR was under general anesthetic and already in a lateral position for a video assisted thoracoscopy.  When prepping the patient, I had placed the defib pads on him because he was sicker than crap.  Just before incision, the rate took off into the stratosphere and the BP as measured by my arterial line dropped like a rock.  The last numbers I saw was a rate of 180 and a SBP of 50.  I sync cardioverted with 200j and knocked him into sinus rhythm.  The surgeon was quite happy and we finished the case after cleaning the infection out of his chest.  He had a rocky ICU course but survived.  The risk of cardioversion is dropping a clot into the brain and stroking out but there really was no choice here.  

May the Tube be with you


Sound like the Afib here was 2/2 the type of surgery and problem the patient was having. I'm going to guess he didn't have a CHADS score that would suggest risk of a LA thrombus. I'd say you were pretty safe in DCCV'ing this guy (not that it sounded like you had  much of a choice.) Good call on the pads. I can't say I'd have thought to do that.

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 I would have been reluctant to give ASA & Nitro to this patient. I would have been more inclined to administer either Amiodarone, Cardizem or Lopressor.

Edited by 1EMT-P

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