Cardiology expert Adele Pope returns with an approach differentiating tachycardia and managing atrial fibrillation. We also discuss ventricular ectopics, bigeminy and peri-operative anticoagulant and anti-platelet adjustment.
* Life threatening
* Common triggers of AFib
* Post operative state
* Myocardial infarction
* Hypo- or hypervolaemia
* Pulmonary embolus
* Electrolyte disturbance
* Cardiac dysrhythmia
* Electrolyte imbalance (especially hypokalemia and hypomagnesemia)
* Fever/ sepsis
* Metabolic disorders
* Poisoning and toxic exposure
* Pulmonary embolism
* Respiratory disease (e.g. pneumonia, pneumothroax)
* Withdrawal syndromes
* ECG and new set of vitals before you arrive
* Eyeball the patient/ABCs
* Old or new tachyarrhythmia?
* Chest pain
* Exact time of onset of symptoms
* Cardiac history
* Prev AF
* Ischaemic heart disease
* Valvular disease
* Heart failure
* Vitals + Examination
* General inspection + peripheries for perfusion
* Confirm rhythm
* Valvular dysfunction
* Calves/leg oedema
* Narrow complex or wide complex?
* QRS > 3 squares could be a wide complex tachycardia (call a code)
* Concordance (V1 – V6 often point in one direction in VT)
* AV dissociation indicated VT
* If narrow complex, is it regular or irregular?
* Irregular is probably AFib
* Consider investigations
* FBC, U&E (including Mg), TFT
* Consider septic workup
* Consider troponin
* Consider observation
* 500 mL fluid bolus
* Metoprolol tartrate 50 mg (not if overloaded or in steroid-dependent asthma)
* Diltiazem short acting 30 mg as an alternative
* Review past notes
* Current medications – has a dose been missed?
* Basics (date/time/name/reason for review)
* Positives and pertinent negatives
* Impression and differential with justification.
* Have you eliminated life threatening conditions?
* Why has this arrhythmia developed?
* Is there a risk of deterioration?
* Type of AFib (first episode, paroxysmal, persistent, or permanent)
* Clear and specific plan
* Immediate investigations
* Electrolytes correction
* Beta blocker?
* Consider echo, TOE, CXR, ETT
* Consider discussion with senior and escalation, especially if called back to patient again.
* Get help early for:
* Wide complex tachycardia
* Poor perfusion/hypotension
* Pulmonary oedema
* Main triggers are post operative state, myocardial infarction, sepsis and anaemia.
* AF may be the first sign of a significant problem, so a good review of systems is needed.
* AF may precipitate cardiac and perfusion problems (ischemia, heart failure, atrial thrombus), so identify patients at risk.
* Assume onset of AF to be greater than 48 hours...