Month: December 2017

AF & tachycardia

AF & tachycardia

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.

Differential

  • Life threatening
    • VT
    • SVT
      • AFib
      • Flutter
  • Common triggers of AFib
    • Post operative state
    • Myocardial infarction
    • Sepsis
    • Anaemia
    • Hypo- or hypervolaemia
    • Pulmonary embolus
    • Electrolyte disturbance
  • Cardiac dysrhythmia
  • Non-cardiac
    • Anemia
    • Anxiety
    • Dehydration
    • Electrolyte imbalance (especially hypokalemia and hypomagnesemia)
    • Fever/ sepsis
    • Hyperthyroidism
    • Hypoglycemia
    • Ischemia
    • Metabolic disorders
    • Pain
    • Poisoning and toxic exposure
    • Pulmonary embolism
    • Respiratory disease (e.g. pneumonia, pneumothroax)
    • Shock
    • Trauma
    • Withdrawal syndromes

Approach

  • ECG and new set of vitals before you arrive
  • Eyeball the patient/ABCs
  • History
    • Old or new tachyarrhythmia?
    • Chest pain
    • SOB
    • Palpitations
    • Exact time of onset of symptoms
    • Cardiac history
      • Prev AF
      • Ischaemic heart disease
      • Valvular disease
      • Hypertension
      • Heart failure
    • ROS
  • Vitals + Examination
    • General inspection + peripheries for perfusion
    • JVP
    • Auscultation
      • Confirm rhythm
      • Valvular dysfunction
    • Wound
    • Calves/leg oedema
  • ECG
    • 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
  • Management
    • 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
  • Documentation
    • 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
    • Fluids
    • Electrolytes correction
    • Beta blocker?
    • Anti-arythmic?
    • Anti-coagulation?
    • Consider echo, TOE, CXR, ETT
    • Consider discussion with senior and escalation, especially if called back to patient again.

Concluding remarks

  • 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.
  • Timing:
    • Assume onset of AF to be greater than 48 hours ago unless there is a clear history of onset
    • AF >48 hours needs anticoagulation prior to cardioversion
    • All patients should be anticoagulated for 2 weeks following cardioversion
  • Bigeminy and ectopics
    • Ventricular ectopics are normal. If >50% of ventricle beats are ectopic, consider structural heart disease.
    • Bigeminy is also often normal (two ectopic beats in a row).
    • Obtain a rhythm strip to determine the frequency of ectopics beats.
    • Discuss with cardiology if >50% or recurring trigeminy.

Resources

Q&A with Dr Deborah Powell

Q&A with Dr Deborah Powell

Foremost expert on all things NZRDA, Dr Deborah Powell, explains why RMOs get free meals, what 8.1.2 is, and the RDA’s role in helping members in trouble.

  • Meals and the NZRDA Education trust
  • 8.1.2
    • “For runs to which the above paragraph does not apply, any Ordinary Hours which are not rostered shall be counted as hours worked (up to a maximum of 8 Ordinary Hours per day) when determining the category for the run.”
  • Role of NZRDA
    • Negotiating and enforcing the MECA
    • Informing members
    • Lobbying
    • Helping and representing individuals in difficulty
    • Media
    • Public relations
    • All things RMOs
  • Getting into trouble
  • Cross cover outside ordinary hours
  • What happens to membership fees?
  • Bullying and harassment