The morning shift in the ED has just started and the nurse approaches about an 85-year-old male from a nursing home who is febrile to 39.5?C, is tachycardic with a heart rate of 160 beats/min, and has a blood pressure of 98/57 mm Hg. He has a history of dementia, diabetes, and hypertension and is nonverbal at baseline. He is minimally responsive and unable to give additional information. You begin fluid resuscitating him and administer acetaminophen, and you notice on the monitor that his heart rhythm is irregular.
What is the safest way to control the patient’s rhythm? Should he be anticoagulated and if so how?
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Last Updated on January 26, 2023
unstable tachycardia,
synchronised cardioversion
Procainamide. Love me that drug. Afib with WPW.
rather than bolus dosing of diltiazem, start a drip at 2.5mg/h.
if this doesn’t work amiodarone 150mg then drip could also work.
All septic pt are high risk for VTE, thus prophylaxis like LMWH is indicated, but considering this patient does not have a hx of a-fib, this metobolic stress is likely the cause of his a-fib. He should not be fully anticoagulated given this is likely an acute event. if the afib continues he would be risk stratified by CHADS2. If his rate was was over 200 and irregular, concern for Afib with underlying WPW would require procainamide.
At this time underlying treatment ( fluid challange test and Antibiotic according to severe sepsis protocol) is enough to control the rate and if the problem exist,Drugs without negative inotropism would be good choice to control the rate.Rhythm control is not necessary in this case,however,ecocardiography and probable anticoagulant therapy should be considered upon early stabilizaytion. Then warfarin with a desired INR=2-3 could be started.
this patient in sepsis due to maybe (UTI) most common,this patient need need full investigation blood +urine and blood and urine culture & electrolytes.
then he need decrease temperature with analgesia . start antibiotic I.V third generation cephalosporin. fluids.no need anticoagulant.then he need again to check heart rhythm.
Correct the underlying sepsis first– fluid resus etc. A fib may be precipitated by underlying sepsis. Also, could give ca channel blocker with an amp of calcium to block peripheral effects and further tank bp, while controlling heart rate centrally.
beside the fluid administration & acetamioophen start O2 by face-mask checkSaO2.
As haemodynamics compromised, I think best way to control heart rate is cardioversion. As this arrhythmia has occurred in the back ground of febrile illness, I m not rushing to commence full anti coagulation straight away. I ll organise further cardiac work up and consider anticoagulation as per risk of thromboembolism.
Procainamide 20 mg/min IV to control the rhythm. Yes, with no known history, he should be anticoagulated first with lovenox at 1mg/kg subcutaneously while orally bridging him on dabigatran or warfarin.
Correction: should say 2 (but up to 6) mg/min IV procainamide. Can load with 100mg q5 mins until drip is ready.
MAT—
atrial fibrillation. yes to anticoagulation as per chads2 score
A fib c RVR very likely.
Cardizem I.V.
Lovenox 1mg/kg SC
first get a 12 lead. if afib w/ rvr? cardiac and IVC US. assess heart function and IVC diameter. tank him up with fluids. cbc, ct head, fast exam and rectal no bleed, heparin and slow him down with ccb if fluid challenge fails
I would administer IV Fluids, obtain routine labs to include ABG, CBC and Chemistries along with a blood culture, a D-dimer and UA. Differential diagnosis at this time would include dehydration, PE, sepsis, atrial fibrillation. I would anticoagulate with Lovenox if he is in atrial fibrillation and obtain a TEE.
ABC…obtain blood results…check ivc compressibility…if suggestive of volume problem, fluid resus first. if suggestive of cardiac cause then do bedside echo, consider cardioversion subjective to blood pressure trend, consider anticoagulant based on what i see on echo and pt/inr. if echo normal, pt/inr normal, BP>90mm/hg systolic, i might consider to anticoagulate him but after ct scan brain. oh yeah i would consider ct scan brain him as early as possible.