There’s a bit of a loophole in the ACLS protocols that allows afib at its worst to get away with murder.
Let’s look at two scenarios and vote about a #cardioversion decision.
#Tachyarrhythmia #tweetorial
1/7
Let’s look at two scenarios and vote about a #cardioversion decision.
#Tachyarrhythmia #tweetorial
1/7
Scenario/poll 1:
70 yo, has severe aortic stenosis, admitted with pneumonia. She was eating dinner -> suddenly complained of palpitations then became unresponsive.
Preceding: BP 98/67, HR 90 in sinus.
Now: BP 48/30, HR 180s in a-fib, pulse very thready but palpable.
Do you:
70 yo, has severe aortic stenosis, admitted with pneumonia. She was eating dinner -> suddenly complained of palpitations then became unresponsive.
Preceding: BP 98/67, HR 90 in sinus.
Now: BP 48/30, HR 180s in a-fib, pulse very thready but palpable.
Do you:
Scenario/poll 2:
Same patient and history: severe aortic stenosis, admitted w pneumonia, sudden palpitations -> unresponsiveness.
VS earlier: BP 98/67, HR 90 in sinus.
Now: BP cuff not reading, HR 180s in a-fib, no convincing pulse.
Do you:
Same patient and history: severe aortic stenosis, admitted w pneumonia, sudden palpitations -> unresponsiveness.
VS earlier: BP 98/67, HR 90 in sinus.
Now: BP cuff not reading, HR 180s in a-fib, no convincing pulse.
Do you:
Let’s think through what happened here. She was preload dependent (AS) and vasoldilated, but hanging in there. Suddenly flips into rapid AF. Loss of atrial kick + very short diastole -> preload & stroke volume tank -> shock. Drastic clinical change from an acute arrhythmia.
4/7
4/7
The difference between the scenarios: in 2, hemodynamics were even more compromised by the arrhythmia, and BP was so low as to not register a cuff reading or pulse.
But in both cases, the afib is killing her, and if we get her into sinus, she can finish dinner. Cardiovert!
5/7
But in both cases, the afib is killing her, and if we get her into sinus, she can finish dinner. Cardiovert!
5/7
But: within ACLS, there’s a big distinction.
Scenario 1 is unstable tachyarrhythmia: cardiovert.
Scenario 2 is PEA: give epi (and do CPR of course, appropriately). But don’t treat the rhythm because it’s not VF/VT.
It really seems like we should...
Scenario 1 is unstable tachyarrhythmia: cardiovert.
Scenario 2 is PEA: give epi (and do CPR of course, appropriately). But don’t treat the rhythm because it’s not VF/VT.
It really seems like we should...
Can’t wait to hear thoughts from #medtwitter, but two safe take-aways:
- In low-preload or preload-dependent states, flipping into rapid afib can dramatically worsen hemodynamics
- It’s hard for any protocol or guideline to include/be right for every patient
7/7
- In low-preload or preload-dependent states, flipping into rapid afib can dramatically worsen hemodynamics
- It’s hard for any protocol or guideline to include/be right for every patient
7/7
