022. Cardiac Rhythm Disturbances

SVT

Trick of the Trade: For valsalva maneuver, use a 10cc syringe and have the patient try to blow out the plunger. This is the equivalent of 40mmHg which is what you want to achieve with the valsalva.

For adenosine push, put the 6 or 12mg of adenosine in a 20cc syringe with normal saline. Then do a single push rather than using the stopcock. Just as effective, not diluted, its stable and goes to central circulation.

 

Atrial Fibrillation

Acute Decompensated Heart Failure with Afib: Is this new onset HF & AF? Is this chronic HF with new AF? Is this chronic HF & AF?

New HF and new AF: electrical cardioversion will likely work.

Vapotherm: high flow nasal cannula: giving PEEP without preload decrease you get with bipap.

Digoxin: treats AF and HF. 500mcg (8-12mcg/kg), peak onset isn’t until 30 minutes, full onset in 4 hours. 50% it works.

Vasopressors: Phenylephrine: pure alpha vasoconstriction. help augment BP was HR improved.

Diltiazem vs Metoprolol: 1.25-2.5mg every 2-5 minutes for metoprolol for AF + HF. If EF > 55%, ok to use both diltiazem (2.5mg per minute, max 25) with metoprolol. Use smaller doses at more quicker times between doses than the ‘large’ dose you usually give.

Amiodarone: If digoxin and metoprolol not working, start 150mg load, up to 300mg; after that, try to cardiovert them. Increases effectiveness of successful cardioversion.

Magnesium: vasodilator but can be used. Also give calcium.

Cardioversion probably faster/more successful than medications. Ibutilide and procainamide if going to use medications. Need to be under 48 hours from onset. Consider looking at ABCD2 score prior to discharge for anticoagulation. Ventricular rate control makes cardioversion worse. (AAEM Blog, 2017)

References

Trick of the Trade: Supraventricular Tachycardia, Michelle Lin, Essentials of EM 2014

Hypotensive Rapid A. Fib with Acute Heart Failure, Semhar Tewelde, The Crashing Patient Conference 2015

022. Cardiac Rhythm Disturbances

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