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Clinical Pearl: The Crashing AFib Patient in the ED

doi: 10.1097/01.EEM.0000513587.42037.7d
Clinical Pearl

BY EMEDHOME.COM

The current approach to the atrial fibrillation patient with a rapid ventricular response who is very hypotensive, of course, is to cardiovert, but this rarely works, especially if the patient is chronically in AF. Instead these techniques may give a better outcome.

* Use maximum energy on the first attempt — this will not cause more cardiac injury than the use of fewer joules — and position the pads optimally. Use AP pad placement (R parasternal and L tip of scapula), which has been shown in some studies to have a higher success rate than typical anterolateral placement.

* The coronary arteries fill during diastole. Raising the diastolic blood pressure >60 mm Hg improves blood flow to the coronary arteries and makes the myocardium less irritable. Use push-dose phenylephrine, 50-200 mcg q 1-2 min PRN, to raise the diastolic blood pressure >60 mm Hg. This will temporize the situation and make the patient's heart more likely to slow down. Phenylephrine is not a chronotrope and adds some vagal tone, which may help with the heart rate.

* Magnesium? No. Recent literature indicates that it is of no benefit.

* Work on rate control now that the blood pressure is a bit higher. Use amiodarone 150 mg slowly to reduce the risk of hypotension. Alternatives are diltiazem and beta-blockers (esmolol). Again, go low and slow: 2.5 mg/min aliquots of diltiazem, for example.

* Now return to the underlying problem of AF. Increase your chances of synchronized cardioversion with pharmacological enhancement. Several agents can be used, but ibutilide has the most supportive data. Pretreating a patient with ibutilide (0.01 mg/kg over 10 minutes, waiting 10 minutes, and then cardioverting) significantly increases the chance of successful cardioversion and the duration of time the patient remains in sinus after cardioversion. (Sources: Heart 1999;82[6]:726; Circ Arrhythm Electrophysiol 2016;9[9], doi: 10.1161/CIRCEP.116.004521; Circulation 2014;130[23]:2071; J Cardiovasc Med 2006;7[2]:124.)

This Clinical Pearl first appeared on EMedHome.com. Subscribers receive a new pearl by email every Wednesday. Visit www.EMedHome.com for more information.

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This Month's Podcast

Amal Mattu, MD: The latest literature on transient ischemic attack, cellulitis, and RBC transfusions in the ED; http://bit.ly/MattuEMN. Dr. Mattu is one of the premier speakers in emergency medicine and a professor of emergency medicine and the vice chair of emergency medicine at the University of Maryland School of Medicine in Baltimore.

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Nilesh Patel, DO: Acute Intermittent Porphyria: An Emergency Medicine Challenge: http://bit.ly/EMN-EMedHomeVideos. Dr. Patel is an assistant professor of clinical emergency medicine at New York Medical College and the emergency medicine residency program director at St. Joseph's Regional Medical Center in Paterson, NJ.

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