[ERRNTraveler]

Last night at work we electrocardioverted a guy in rapid a-fib. No big deal, except he had come in to the ER already in a-fib, so he had been in a-fib for an unknown amount of time- maybe hours, maybe days, maybe longer.....

Now, I thought electrocardioverting someone out of a-fib was a big no-no unless the time of onset was known because of the risk of dislodging a clot. Shouldn't he have been anticoagualated first? He was not given ANY anticoagulants before we converted him back to sinus rhythm, and he was perfectly stable prior to converting him. When I asked the doctor if he didn't want the patient to receive some sort of anticoagulant before converting the pt, the doc looked at me like I was crazy, proceeded to do the electrocardioversion, and then discharged the patient an hour later...

Am I way off base here, or is there just something not right about this????

[dianah]

Below is the link to the ACC site's section on treatment of atrial fibrillation (section 8 of the ACC Guidelines).

http://content.onlinejacc.org/cgi/reprint/48/4/e149

It depends on
**how long the pt has been in afib,
**if any oral or IV antiarrhythmics/rate reduction agents have been administered (with refractory rhythm), AND
**how well the pt is tolerating the rapid rate.
If the patient is unstable, of course, immediate DC cardioversion is indicated.

I know for our elective cardioversions the pt is fully anticoagulated (INR >2) and a TEE is performed within 24 hr of the cardioversion, to evaluate the LA (and more specifically, the LAA [left atrial appendage]) for clots. If there are no clots, the pt is cardioverted and then started on oral antiarrhythmics.

My sources tell me the standard of care varies (i.e., not everyone follows the ACC guidelines) from place to place, and that some MDs are more "old school" in their treatment decisions.

[nialloh]

Originally Posted by dianah

Below is the link to the ACC site's section on treatment of atrial fibrillation (section 8 of the ACC Guidelines).

http://content.onlinejacc.org/cgi/reprint/48/4/e149

It depends on
**how long the pt has been in afib,
**if any oral or IV antiarrhythmics/rate reduction agents have been administered (with refractory rhythm), AND
**how well the pt is tolerating the rapid rate.
If the patient is unstable, of course, immediate DC cardioversion is indicated.

I know for our elective cardioversions the pt is fully anticoagulated (INR >2) and a TEE is performed within 24 hr of the cardioversion, to evaluate the LA (and more specifically, the LAA [left atrial appendage]) for clots. If there are no clots, the pt is cardioverted and then started on oral antiarrhythmics.

My sources tell me the standard of care varies (i.e., not everyone follows the ACC guidelines) from place to place, and that some MDs are more "old school" in their treatment decisions.

On my unit we also keep the pt for at least 24hr in case they convert back (which sometimes happens). They are also started on antiarrythmic meds. I don't understand why the MD would DC the pt after 1 hr, far far too soon.

[Altra]

I've seen this proceed as you describe.

If patients come in to the ER, they're probably symptomatic.

We even have a couple of cardioversion frequent flyers ...

Some patients get admitted, others go home 60-90 minutes later.

[Happeetxn]

Where I work, if the date / time of onset isn't known the pt gets a TEE (Trans-esophageal echo cardiogram) to verify there is no blood clot.

Craig

[RN1980]

i think the issue wheather or not they get anticoagulated or zapped is depending on if the pt is stable or showing s/sx of uncompesation from the high rate or the nature of the rhythm itself. i've seen in many cases where the er doc will try to heparin/lovenox iv and put on a cardizem gtt for more of a rate control vs rhythm conversion, then we'll get a patient whos sob, with a sub-par b/p, heck we'll just put the juice to him. admitting him to the hospital vs d/c depends on some other factors, but i've seen a-fib tx'd different ways, but dislodging a clot is a possibility with a sudden complete rhythm change with the slowing of the rate, in any case i think you were correct in your intervention with anticoagulation unless the patient was borderline unstable.

[rjflyn]

I had a co-worker, in his early 50's, a number of years ago go in to a-fib on a Thursday. They spent the weekend using various agents attempting to convert him. All the time the were anti-coagulating him as well. He told me he basically fell like "****" the whole time. On Monday morning they finally cardioverted him back to sinus rhythm. He stated from that day forward he would absolutely refuse any other treatment beyond maybe one attempt at Adenosine. He said he would tell them to shock him or he would AMA and go someplace that would.

Rj