Comments on: EMCrit Podcast 20 – The Crashing Atrial Fibrillation Patient

By: emcrit

emcrit — Sat, 27 Mar 2010 07:51:41 +0000

I believe its cardioversion; the machine should still be able to sync on the R wave. I’ll add tachy rhythms to the future show list. thanks for listening.

Scott

By: Shagle

Shagle — Tue, 23 Mar 2010 20:25:42 +0000

Thanks for this podcast.
Can you do one on all remaining tachyarrythmias!
Regarding shock is it defibrillation or cardioversion in atrial fib with lo BP!.

By: emcrit

emcrit — Sat, 20 Feb 2010 16:39:39 +0000

Calcium showed good effect as a pretreatment for verapamil. The data have not supported Ca pretreatment for dilt (J Emerg Med. 2004 May;26(4):395-400). However even though this study was an RCT, it was fairly useless b/c almost none of the patients got hypotensive in either group. However, calcium is an excellent inopressor in any patient, so I heartily agree that it would be a great thing to give in the patient above. Thanks for the comment.

Scott

By: DR Mohd Anizan Aziz

DR Mohd Anizan Aziz — Fri, 19 Feb 2010 04:56:49 +0000

Dear Scott,

I ve read about the use of calcium as a pre treatment agent prior the use of calcium channel blockers ie ditialzem. They advocated us to give 5-10cc of calcium gluconate as to offset the hypotensive effect of the drug.
What do you think?

By: emcrit

emcrit — Sun, 14 Feb 2010 19:43:40 +0000

Paul,

Thanks for the info and the comment. It sounds like metaraminol is very similar to phenylephrine. So you folks start with the higher dose of amio right off the bat? Do you see a lot of hypotension from it?

scott

By: Paul Hui

Paul Hui — Sun, 14 Feb 2010 11:09:11 +0000

Great talk about a scary topic.
In Australia, instead of phenylephrine, Metaraminol (Aramine) is a more popular drug, It is a fast acting peripheral vasocontrictor, loved by most anesthetist. In common practice, most doctors would mix one ampoule (2 mg) with Normal Saline to make up 20 ml and give one to two ml at a time. The bolus dose of Amiodaro0ne recommended is 3oomg followed by an infusion. I came across a similar case of crashing AF > 170 and hypotension 70/50 not long ago. To make the situation worse, he had infective COPD /type 2 respiratory failure with a high pCO2 of 85. Fortunately, the emergent cardioversion worked and he improved on NIV.

By: emcrit

emcrit — Sun, 14 Feb 2010 01:55:54 +0000

In response to your latest blog,

Would you prefer metoprolol for rapid afib if the pt is already on it?

For years, I’ve been encouraged to avoid using more than one class of AV blocking agents at a time if avoidable. Most chronic Afib pts come in on metoprolol, sometimes in addition to another agent (e.g. Digoxin). I have the most experience with diltiazem for treating rapid afib, but would it make sense to start with metoprolol for this patient, as we may avoid combining agents to increase the chance of causing complete heart block? It seems like the ED usually prefers dilt, while cardiology often prefers metoprolol.
P.S. What about procainamide for unstable Afib with WPW?
Thanks.

I wouldn’t consider the patient’s home meds to contraindicate your choice in the ED. I think the way to go is to avoid giving two classes of meds IV. Procainamide is just built to lower the pt’s BP, so even with phenylephrine, I think you are better off avoiding it in a hypotensive patient. But if they are not shocking out, you can consider it.

By: emcrit

emcrit — Sat, 13 Feb 2010 18:45:29 +0000

No reason you can’t. I just have not found them to be as effective as dilt or amio.

By: theunis johan

theunis johan — Sat, 13 Feb 2010 18:38:03 +0000

Dear Scott,

Why don’t you use beta blokkers to slow them down?

By: emcrit

emcrit — Sat, 13 Feb 2010 05:58:38 +0000

hee hee

By: Chris Nickson

Chris Nickson — Sat, 13 Feb 2010 05:35:50 +0000

I’m sure the cardiology consult will make everything better…
C