Atrial Fib. Noninvasive Treatment - page 4

Hi Everyone Just Wondering What Are Some Non Invasive Treatments For A. Fib.?... Read More

  1. by   papawjohn
    Hey Y'all

    Gosh, qanik--had the heart rate (Says P- J- who's been on the ol' treadmill and under the nuc med sensor hisself.)

    When I worked in cardiac stepdown there were two BIG things I learned to watch for. The first and worst was a CVA. Presumably AFib would occur post op--or the time on pump, who knows--would produce a 'mural thrombus' in the Left Atrium. Restoring NSR would 'break a piece off' and the embolus would find its way into (usually) the Left Middle Cerebral Artery. The result was usually typical--Right side flaccid, aphasia, confusion.

    The second and coolest was what we called 'post-open-heart-syndrome'. (I think it's actually Dresslers Syndrome?) Pericarditis leads to inflamatory myocarditis. Your Pt has a mild fever, develops a rub, converts to AFib. (It's what got yer ol' Papaw listening to heart sounds 25 yrs ago.) It's quickly reversed by NSAIDS or SoluMedrol and a Calcium Channel Blocker. You call the Cardiologist at 10pm, start the med by midnite, and you have a reversal by 0600. COOL!!!

    Thinking what a great profession we've got
    Papaw John
    Last edit by sirI on Nov 4, '05
  2. by   ceecel.dee
    Very educational thread for me!
    Thank you very much!
  3. by   RN12345656
    Quote from heartnurseinva
    Dinith--AtriCure is very similiar to Maze procedure except sternotomy and pump are avoided with just a thoracotomy approach. EP lab ablation is obviously less invasive than AtriCure.
    I'm sorry--it's a thoracoscopy approach (smaller incision than an actual thoracotomy)
  4. by   Dinith88
    Quote from heartnurseinva
    I'm sorry--it's a thoracoscopy approach (smaller incision than an actual thoracotomy)
    Thanks a bunch for the info!
  5. by   JustMe
    Quote from papawjohn
    Hey Again

    OK...Here's the story if your Pt goes into a rapid atrial rhythm or SVT. Your role is to get them back into NSR as soon as possible. (Do I get extra credit for NOT saying NSR ASAP?)

    There's two ways this happens. First, the Pt might say--"Wow, I've done it again." This is the time to use your nursing judgement and say: "What works for you at home?" Lots of people have this experience at home and they do all kinds of things: They dip their face into ice water. Or they rush to the toilet and try to have a BM.

    Whatever works for them at home, help them.

    If that doesn't help them in the hospital, you have to decide if they"re going to need something special. If the rhythm is really rapid and probably ventricular (I say this because at this point it's 0200 and your looking at the screen of the CodeCartMonitor) you say "bear down like you're going to have a BM!!"

    Nine times outa ten, this doesn't work and you're on the phone to the MD very shortly after. (There are alternatives--carotid massage--but we're not gonna do that without an MD on hand giving verbal orders. And if he's on hand, make him DO IT.)

    Then you give digitalis and/or cardizem. Then about 5 times outa 10 the Pt returns to NSR.

    For the rest, see my previous post....

    Papaw John


    I agree with everything you said Papaw John--except if the patient has had an acute MI. Have you ever had a pt with AMI on the commode, bearing down? Watch them brady down?? Not pretty! If you want them to bear down, put them on a bedpan, otherwise you could have more than a code brown!
  6. by   papawjohn
    Hey JustMe

    Oh HONEY!!! There're a couple of hilarious 'nursing humor' stories that I'd prob'ly get in trouble for putting on this thread. They involve BedSideCommodes and Blue/Brown codes.

    And yes, I have Atropine in my pocket and Adensosine drawn up and etc etc when this kinda thing happens. I'm the kinda guy that likes to have a few 10cc syringes of Saline for flushes nearby. I'm a 'just in case' kinda nurse. (If you have it in your pocket--you probably won't need it.)

    Papaw John
  7. by   JustMe
    Quote from papawjohn
    Hey JustMe

    Oh HONEY!!! There're a couple of hilarious 'nursing humor' stories that I'd prob'ly get in trouble for putting on this thread. They involve BedSideCommodes and Blue/Brown codes.

    And yes, I have Atropine in my pocket and Adensosine drawn up and etc etc when this kinda thing happens. I'm the kinda guy that likes to have a few 10cc syringes of Saline for flushes nearby. I'm a 'just in case' kinda nurse. (If you have it in your pocket--you probably won't need it.)

    Papaw John
    LOL!! Murphy's Law!!
  8. by   rookreck
    At my facility if the time of the onset is known and is a new occurence we anticoagulate and try to use drugs (IV Cordarone) to convert them. If the patient has been in afib for a long period of time we slow them down with Cardizem and Lopressor and anticoagulate them and send them home. After a period of time the patient is brought back in and placed on IV cordarone for 24 hours and if they don't convert to NSR then we cardiovert after the 24 hours and the patient is sent home on po cordarone.
  9. by   TennRN2004
    And as far as a reason for a-fib from AVR's (and any other heart surgery...but especially from valves) is mostly from endocardial edema caused by the procedure itself (and compounded by electrolyte abnormalities, etc.). This 'irritation' can take upwards of a month to subside. As far as how long they typically keep these people on meds (post-op hearts triggering afib) to control it i'm unaware (meaning if they've converted...if still in afib they onbviously could be on them for life).Thats a good question for a surgeon (or cardiologist) i suppose...[/quote]

    We started using a beta blocker protocol at my hopsital (about a year ago I think) to try and prevent CAB post op AFib. I don't have the actual numbers, but one of our heart surgeons a couple of weeks ago said he thought the post AFib rates had went from 30% down to about 10% now with the use of Atenolol and Cordorone preop and postop. Of course, we do have the patients who have a history of AFib who still go into it post op and may or may not convert to NSR, and we also have those who pop in and out of Afib/SR- they stay on anticoags and usually drugs like Dig for rate control, but overall it seems to be a good protocol we use. The only problem is now all of our CAB pts (I was surpised some of our surgeons didn't put epicardial wires in their patients just in case anyway) come out with pacing wires in case they go bradycardic from the meds and need to be temp paced for a while, but the surgeons don't like that either.
  10. by   rcpals
    Hey guys this is my first post...

    This is what the AHA says about A-fib and A-flutter (they both have the EXACT same treatment / algorithm)

    The first question that must be asked after identification of AF/AF (or any tach, wide or narrow except the automatic tachs MAT,JT,ST ) is:

    Question #1 "Is the patient stable or unstable".

    You must remember these general rules:

    Stable = drugs (we have a little time)

    Unstable = immediate synchronized cardioversion for all patients except the automatic tachycardias (MAT, JT, ST).

    This is an absolute rule because we have no time! Every minute we wait leads to organ hypo-perfusion that leads to MOF (multi organ failure) which has a 40-80% mortality rate.

    American heart feels that afib > 48 hours = left atrial clots.

    If someone has afib for less than 48 hour you may convert the rhythm (chemically or electrically, both are acceptable) immediately because we dont have the fear of left atrial clots.

    The AHA guidelines for stable AF = Anticoagulate, control the rate and convert the rhythm.

    Stable afib for > 48 hours we must:

    *Begin anticoagulation (for 3 weeks) because of high probability of left atrial clots.

    * Control the rate if afib out of control (greater that 100 usually >120 +++)

    Remember the faster the heart rate the less efficient it becomes. Calcium channel blockers, beta blockers or dig are acceptable. Diltiazem is the preferred drug over verapamil (it has a less negative inotropic affect) Beta blockers are also acceptable. Do not give amiodarone because it might control the rate but might inadvertently convert the rhythm (it can do both). Dig takes the longest to control the pt. We don't use poly drugs / multi antiarrhythmics. It causes arrythmias.

    * Convert the rhythm: After 3 weeks of anticoagulation bring the pt into the hospital, perform a TEE (trans-esophageal echocardiogram, which is about 95% accurate for ruling left atrial clots). If there are no clots you may convert the rhythm. Post cardioversion care, is to place the pt on anticoagulants for an additional 4 weeks.

    * This is called delayed cardioversion


    Some MDs have a problem leaving there pt in new onset afib for three weeks while we antiacoag our patient. Remember, the longer the patient remains in afib, it might become their permanent rhythm. Some MD's, if it's close to the 48 hour window, will perform a TEE in the ER and if no atrial clots will cardiovert the pt immediately and then send them home on 4 weeks of anticoagulation. This is called early cardioversion.

    For unstable afib or any unstable tachs, wide or narrow except the automatic tachs (MAT, JT, and ST) we use immediate cardioversion. Period.

    Remember what unstable means and looks like. Are there signs of shock or hypo-perfusion? Is the patient hypotensive, cold and clammy with mottled color and thready pulses? Are there crackles halfway up the lungs? Does the pt have chest pain or SOB or ALOC? These common signs scream severe life threatening shock. We have to act fast. Someone's mom or dad is begging us "please save me"!


    Unfortunately, many clinicians allow their pt to remain hypotensive for a prolonged time while other things or tests are done. If someone is hypotensive and symptomatic, we must act quickly! Every minute of hypotension leads the patient towards multi organ failure (MOF).

    MOF has the highest mortality rates of almost all ICU admissions (40-80% depending on how many organ systems are injured).

    Think about what a single prolonged (or not) hypotensive insult to the organs will do. Would the organs be injured from cellular hypoxia? Yes. What happens when we injure something? It becomes swollen and edematous by the hour.

    Question: Why are the organs injured?

    Answer: From cellular hypoxia. Imagine if you punched a brick wall and broke your hand in multiple places. Would it become swollen? Of course. Could you use your swollen and injured hand well? No, your hand would not function well.

    Now, picture the swollen and heavy kidneys that gradually stop producing urine because their so badly injured by cellular hypoxia. So what's the treatment? Cautious fluids, diuresis or dialysis, dopamine etc... This is the beginning of MOF.
    (organ system dysfunction #1)

    The lungs also become swollen and heavy and stop oxygenating and ventilating well so we have to increase Fio2 and Peep and ventilatory support.
    (organ system dysfunction # 2)

    The gut dies and becomes necrotic = dead bowel + surgery
    (organ system dysfunction # 3)
    Etc... You get the point.


    Question: Why do we use IMMEDIATE synchronized cardioversion for all unstable tachs (except the automatic tachs MAT, JT)?

    Answer: Cardioversion is the definitive treatment for unstable tach. We do use concurrent administration of anti-arrhythmics. We ensure effective oxygenation (generally NRB) while preparing for immediate synchronized cardioversion with 50-100-200-300-360 joules in a step wise approach. Some docs start at 50j, some at 200j or higher. We don't sedate or wait for an IV it just wastes precious time. We immediately cardiovert.

    Question: If our pt was unstable, had all the classic signs of hypoperfusion but had afib for > 48 hours ( a high likely hood of atrial clots) would we use immediate cardioversion ?

    Answer: Yes, what other option do we have. If we don't convert the rhythm the patient will die form cellular hypoxia > MOF. We have to cardiovert immediately. If the patient did throw a embolic stroke we would use fibrinolytics. Were picking the lesser of two evils on that one. Hope this helps...

    Jeff RCP

    Anaheim CA
    Last edit by sirI on Jan 10, '06 : Reason: TOS
  11. by   Dinith88
    Quote from rcpals
    Hey guys this is my first post...

    This is what the AHA says about A-fib and A-flutter (they both have the EXACT same treatment / algorithm)

    The first question that must be asked after identification of AF/AF (or any tach, wide or narrow except the automatic tachs MAT,JT,ST ) is:

    Question #1 "Is the patient stable or unstable".

    You must remember these general rules:

    Stable = drugs (we have a little time)

    Unstable = immediate synchronized cardioversion for all patients except the automatic tachycardias (MAT, JT, ST).

    This is an absolute rule because we have no time! Every minute we wait leads to organ hypo-perfusion that leads to MOF (multi organ failure) which has a 40-80% mortality rate.

    American heart feels that afib > 48 hours = left atrial clots.

    If someone has afib for less than 48 hour you may convert the rhythm (chemically or electrically, both are acceptable) immediately because we dont have the fear of left atrial clots.

    The AHA guidelines for stable AF = Anticoagulate, control the rate and convert the rhythm.

    Stable afib for > 48 hours we must:

    *Begin anticoagulation (for 3 weeks) because of high probability of left atrial clots.

    * Control the rate if afib out of control (greater that 100 usually >120 +++)

    Remember the faster the heart rate the less efficient it becomes. Calcium channel blockers, beta blockers or dig are acceptable. Diltiazem is the preferred drug over verapamil (it has a less negative inotropic affect) Beta blockers are also acceptable. Do not give amiodarone because it might control the rate but might inadvertently convert the rhythm (it can do both). Dig takes the longest to control the pt. We don't use poly drugs / multi antiarrhythmics. It causes arrythmias.

    * Convert the rhythm: After 3 weeks of anticoagulation bring the pt into the hospital, perform a TEE (trans-esophageal echocardiogram, which is about 95% accurate for ruling left atrial clots). If there are no clots you may convert the rhythm. Post cardioversion care, is to place the pt on anticoagulants for an additional 4 weeks.

    * This is called delayed cardioversion


    Some MDs have a problem leaving there pt in new onset afib for three weeks while we antiacoag our patient. Remember, the longer the patient remains in afib, it might become their permanent rhythm. Some MD's, if it's close to the 48 hour window, will perform a TEE in the ER and if no atrial clots will cardiovert the pt immediately and then send them home on 4 weeks of anticoagulation. This is called early cardioversion.

    For unstable afib or any unstable tachs, wide or narrow except the automatic tachs (MAT, JT, and ST) we use immediate cardioversion. Period.

    Remember what unstable means and looks like. Are there signs of shock or hypo-perfusion? Is the patient hypotensive, cold and clammy with mottled color and thready pulses? Are there crackles halfway up the lungs? Does the pt have chest pain or SOB or ALOC? These common signs scream severe life threatening shock. We have to act fast. Someone's mom or dad is begging us "please save me"!


    Unfortunately, many clinicians allow their pt to remain hypotensive for a prolonged time while other things or tests are done. If someone is hypotensive and symptomatic, we must act quickly! Every minute of hypotension leads the patient towards multi organ failure (MOF).

    MOF has the highest mortality rates of almost all ICU admissions (40-80% depending on how many organ systems are injured).

    Think about what a single prolonged (or not) hypotensive insult to the organs will do. Would the organs be injured from cellular hypoxia? Yes. What happens when we injure something? It becomes swollen and edematous by the hour.

    Question: Why are the organs injured?

    Answer: From cellular hypoxia. Imagine if you punched a brick wall and broke your hand in multiple places. Would it become swollen? Of course. Could you use your swollen and injured hand well? No, your hand would not function well.

    Now, picture the swollen and heavy kidneys that gradually stop producing urine because their so badly injured by cellular hypoxia. So what's the treatment? Cautious fluids, diuresis or dialysis, dopamine etc... This is the beginning of MOF.
    (organ system dysfunction #1)

    The lungs also become swollen and heavy and stop oxygenating and ventilating well so we have to increase Fio2 and Peep and ventilatory support.
    (organ system dysfunction # 2)

    The gut dies and becomes necrotic = dead bowel + surgery
    (organ system dysfunction # 3)
    Etc... You get the point.


    Question: Why do we use IMMEDIATE synchronized cardioversion for all unstable tachs (except the automatic tachs MAT, JT)?

    Answer: Cardioversion is the definitive treatment for unstable tach. We do use concurrent administration of anti-arrhythmics. We ensure effective oxygenation (generally NRB) while preparing for immediate synchronized cardioversion with 50-100-200-300-360 joules in a step wise approach. Some docs start at 50j, some at 200j or higher. We don't sedate or wait for an IV it just wastes precious time. We immediately cardiovert.

    Question: If our pt was unstable, had all the classic signs of hypoperfusion but had afib for > 48 hours ( a high likely hood of atrial clots) would we use immediate cardioversion ?

    Answer: Yes, what other option do we have. If we don't convert the rhythm the patient will die form cellular hypoxia > MOF. We have to cardiovert immediately. If the patient did throw a embolic stroke we would use fibrinolytics. Were picking the lesser of two evils on that one. Hope this helps...

    Jeff RCP

    Anaheim CA
    dont think the OP wanted a regurgitation of ACLS algorhythms and such.

    And i didnt quite get the gist of your post...can you repeat it?
  12. by   rcpals
    Hi Dinith and thanks for the post.
    First lets understand one basic thing. The AHA algorythms are community standards and we should be using it on most patients. This is not to say we can't deviate from AHA guidelines and try a new technique or drug if we have sound scientific evidence that shows the new technique or drug is as or more effecitive than the "standard". Bottom line. You should be using the ACLS protocols for all afib patients as a community standard. Im sure you get the gist : ) Have a great day... :hatparty:


    "Anybody know if there's a logarithm or protocol for Acute A-Fib that Dr's learn or count on?

    Papaw John"

    That was the question I was answering : )

    Jeff RCP
  13. by   HappyNurse2005
    I have post op cabg pt's on my unit. They are all on PO amio, and nasal bactroban as a preventative to afib.
    Of course, there are always a few (who don't have a hx of afib) who go into afib anyways.
    A cardizem bolus/drip usually takes care of that problem.

close