Episode 191: Rapid Atrial Fibrillation

We go over the treatment of rapid atrial fibrillation (afib with RVR).

Hosts:

Brian Gilberti, MD

Jonathan Kobles, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Rapid_Atrial_Fibrillation.mp3

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Tags: Cardiology

Show Notes

Understanding AF with RVR Categories

General AF with RVR: Definition and basic understanding.

Rapid AF with Pre-excitation: Characteristics and complications.

Chronic AF in Critical Illness: Identification and special considerations.

Stability Assessment in AF with RVR

ACLS Protocols: Distinction between unstable and stable patients.

Unstable Patients: Immediate need for synchronized cardioversion, standard dose at 200 J for adults.

Stable Patients: Rate vs. rhythm control strategies, consideration of underlying etiology.

Limitations in Chronic AF: Challenges in patients with AF secondary to critical illness.

ACLS Guidelines and ECG Findings

Tachycardia with a Pulse Approach: Initial assessment guidelines.

ECG Interpretation:

Irregularly Irregular Rhythm: Absence of discernible P waves.

Ventricular Rate: Typically over 100 bpm.

QRS Complexes: Usually narrow, alterations in the presence of bundle branch block or ventricular rate-related aberrancy.

Identifying Pre-Excitation Syndromes: Signs of shortened PR interval and slurred QRS, indication of Wolff-Parkinson-White Syndrome.

AF with Pre-Excitation (WPW Syndrome)

Risk Assessment: Dangers of using AV nodal blockers (BB/CCB, digoxin, adenosine).

Alternative Management: Utilization of procainamide or amiodarone for stable patients, synchronized electrical cardioversion for unstable patients.

Treatment Approaches for AF Types

General Rapid AF:

First Line Agents: Metoprolol vs. Diltiazem.

Metoprolol Considerations: Dosing (5 mg every 10-15 minutes, max 15 mg), benefits in CAD and HF, limitations in asthma/COPD patients.

Diltiazem Advantages: Faster action, suitability in asthma/COPD, typical dosing (0.25 mg/kg initial, followed by 0.35 mg/kg if needed).

Critically Ill Patients: Tailoring treatment to underlying pathology, avoiding typical AF pharmacologic treatments.

Systematic Evaluation of Tachycardia Causes (TACHIES Mnemonic)

Thyrotoxicosis, Alcohol withdrawal, Cardiac issues, Hemorrhage, Intervals (WPW), Embolus, Sepsis.

Application of the mnemonic for a comprehensive approach to differential diagnosis.

Ultrasound in Diagnostic Assessment

Application in Undiagnosed Tachycardia: Identifying EF, pericardial effusion, valvular pathology, and signs of pulmonary embolism.

Fluid Status Evaluation: Use of ultrasound for assessing b-lines in lung scans.

Management of Chronic AF with HD Instability