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...