Atrial Fib. Noninvasive Treatment

  1. Hi Everyone Just Wondering What Are Some Non Invasive Treatments For A. Fib.?
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  2. 56 Comments

  3. by   pricklypear
    medication
  4. by   papawjohn
    Hey Theoneguy

    Had a stir in my family recently when a cousin emailed all the nurses in my family (several MDs also) that her mom, my aunt, had Atrial Fib diagnosed.

    Wow---I wish I could encapsulate all the EMails we sent my cousin. They'd answer your question. Here's the calmed down version....

    There are two immediate concerns. #1 is the heart rate. Typically when someone first goes into AFib, their pulse rate really really zooms. I've seen people in their sleep with 'new-onset-' AFib with rates ~ 130 to 140. This is too fast for the heart to fill up between beats. So the 'stroke volume' is low. And the BPressure tends to be low--particularly the orthostatic BP.

    So we need to control the rate. In the ICU/CCU the first thing we do is give calcium channel blockers as an IV drip. (Maybe--Diltiazem 10mg push and drip of 10mg/hr--increase to 15mg/hr prn, would be typical orders.)

    Then you have the clotting mechanism to think about. Since the Atria are not 'beating' (they're only squirming about--'fibrillating') the blood can clot in the atrium of the heart. The flow of blood thru the heart leaves the zone near the walls of the atrium with no flow. You can see that, right? The clot that forms against the wall of the atrium is called a 'Mural Thrombus'. That's pretty descriptive isn't it?

    Well, as it turns out, Atrial Fib is the leading cause of strokes. Since pieces of that 'mural throbus' break off and circulate into the brain. So we have to anti-coagulate the Pt.

    The best thing we can do for this Pt is restore them to NormalSinus Rhythm. (Big surprise, right?) Sometimes we 'shock' them with much less voltage than when the Ventricals are in fibrilation (like 60-100joules). Drugs are used before and after this. The best is the oldest--digoxin. (Thank goodness that you'll never have to brew foxglove tea, eh?)

    If you've tried to restore NSR and you've anti-coagulated the Pt (with a heparin drip and started coumadin) and you're giving something to control the rate (like digoxin or Cardizem), you're taking care of your Pt in Atrial Fibrillation.

    Way to go, Bud.

    Papaw John
  5. by   thatoneguy
    wow thanks. i like the way you put it. however i do understand what is going on but i think many will like that. guess i should of said non med. have you ever used the vagal maneuver to treat it. if so how often does it work? o and the face in freezing water is for SVT right?
    Last edit by thatoneguy on Oct 22, '05
  6. by   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
    Last edit by papawjohn on Oct 22, '05
  7. by   thatoneguy
    very nice thanks
  8. by   Dinith88
    Quote from thatoneguy
    very nice thanks
    Patient: " I cant breath and i have palpitations...please help.."

    Nurse: " Try to poop yourself..."

    Patient: " What?!?! I cant breath..."

    Nurse: " Trust me, i'm a professional...bear down like you are taking a poop..."

    Patient: "..oh man...i'm gonna die!!...CALL MY DOCTOR!..."

    Nurse: "...anyone ever put your face in a bucket of ice-water?..."

    Patient: "????? CALL MY DOCTOR!!!"

    I've seen a situation similar to this. What a freakin absurd moment. In my experience, vagal maneuvers rarely work...and if it does anything it usually just slows it down.

    And as far as your origional question...which was answered quite well by the first responder... the best 'non invasive' treatment of AF is meds.
  9. by   thatoneguy
    lol yeah i can just see myself telling a patient to try to have a bm and seeing the look on their face, too funny. i ask about non-invasive "my bad meant non med" because in my acls class they are asking what to do if you have nothing else with you. actual senerio is after math in a situation like New Orleans. so meds are not a option in this senerio. however i will more than likely have some questions about meds later, i am sure about that. thanks for all the help much appreciated, thanks again.
    Last edit by thatoneguy on Oct 22, '05
  10. by   austin heart
    Quote from Dinith88
    the best 'non invasive' treatment of AF is meds.
    It depends on if it is acute or chronic. If acute, cardioversion is the best treatment. Shock em' and send them home. I think that I would prefer that rather than being started on the Cardizem drip.
  11. by   papawjohn
    Hey Y'all

    I got to thinking, it's been a long time since I've seen a cardioversion for AFib. We used to do it alot. Hummm.

    Cardioversion works better if you give drugs (usually dig) first.

    I started doing this work before CalciumChannelBlockers. I wonder if Docs use cardioversion AFTER giving Cardizem & digitalis now-a-days.

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

    Papaw John
  12. by   austin heart
    I only work weekends and we do a good deal of them in the ER if the EP docs are on call. I have at times done 3-4 in one day. We do them most times without giving drugs first. As I said, shock em' and send them home. Sometimes if the rate is high we will give the Cardizem to get the rate down before the cardioversion but not always if the EP guy is in house. I have never seen Dig given before hand. Most often they want them off the Dig with a planned cardioversion.
    We have a protocol for pretty much everything except A-fib, LOL.
  13. by   zambezi
    It is funny that this thread came up. I see a lot of AFib- we had a guy hitting a HR of 200 this week- the highest that I have seen in a couple of years.
    It took a long time to convert him- we did get him to slow to 140-150 with dig and cardizem, then we added amiodarone after the other two were doing much. Thankfully the guy was fairly stable and tolerating the rate without much trouble.

    Our facility does everything already mentioned (though we haven't been cardioverting much lately either...but most of our cardioversions are probably done on an outpatient basis- or on day shift )
    We do occassionally cardiovert at night if the patient is really symptomatic and meds aren't working or we are having BP issues....

    OUr typical drugs for AFIB:
    Digoxin, Cardizem, Amiodarone (these are the three most common for us in a acute situation, though of course there are other choices)

    As for vagal maneuvers- I think that these are great to try while you are pulling out your meds (as dinith said- I have rarely seen them actually work for long, if at all. I have had a patients in "stable" VT use it and it worked for a few times- until they went into VF- but at that point our meds were ready to give the the code cart was ready to go, so at least it bought us time)
  14. by   Dinith88
    Quote from austin heart
    I only work weekends and we do a good deal of them in the ER if the EP docs are on call. I have at times done 3-4 in one day. We do them most times without giving drugs first. As I said, shock em' and send them home. Sometimes if the rate is high we will give the Cardizem to get the rate down before the cardioversion but not always if the EP guy is in house. I have never seen Dig given before hand. Most often they want them off the Dig with a planned cardioversion.
    We have a protocol for pretty much everything except A-fib, LOL.
    AustinHeart,

    Thats unusual (and dangerous) the way you're describing a-fib cardioversions in ER. The biggest reason for that not being good medicine is because in elective cardioversion for a-fib the pt is at big risk for embolism and should be adequately anti-coagulated first. An echo is obtained before-hand to r/o thrombus, etc. Also, as a few have stated, meds are vital to keep the AF from recurring (which, unfortunately, occurs alot w/af cardioversions).
    If someone walks into the ER with A-fib (especially new a-fib), a work-up is in order and the patient gets (should get!)admitted, buys a cardiologist, etc. And if someone walks into the ER with chronic a-fib and gets shocked, they're VERY likely to relapse...especially if (as you say) they're taken off dig., no drugs, etc.
    Meds are always the first choice (rate control, etc.)...and then if pt remains symptomatic a cardioversion may then be in order...under controlled conditions...

    You may not have seen it (yet), but when one of these "3-4 af cardioversions a day in the ER" throws a clot, dies of ventricular standstill (from cardioversion), or otherwise does poorly, i'm betting your er will change its ways. Until then, your er is acting dangerously and is potentially setting itself up for bad things.

    Lastly, if the rate is way up and patient is unstable, of course your hands may be tied and emergent cardioversion would be neccessary. However, an unstable a-fib refractory to meds is the exception (big exception) rather than the norm. It's too bad that its not as easy as 'shock em and send them home'...

    (my entire post may be wrong if you were meaning your hospital schedules elective cardioversions for a-fib...which are then done in er (weird??- slow er??) rather than in an ep-lab, CCU, CardiacIMCU, etc. These folks would then surely have had work-ups, been anticoagulated, etc.)

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