[TooterIA]

Are there any IV meds that you can give to help decrease the HR but it wont decrease the BP? I had a patient last night that his uncontrolled A-fin was in the
150's but his pressure was only 70 and 80 systolic and that was on Dopamine, I forget how many mics but it was 39 ml/hour of the premix. The pt was comfort care only so the Dr wasnt being very proactive, I was just wondering what else we could have done. It seems like his poor hurt would have been plugging away way too hard at that rate.
Jessica

[Sweetooth EMT-P, RN]

hi,

His uncontrolled rate was more than likely a compansation for the hypotension instead of the uncontrolled rate causing the hypotension. It woudl be VERY unlikely that a rate of 150 would cause signficant hypotension without very serious end-stage cardiac disease. Also dopamine increases heart rate as well so that would also cause an uncontrolled ventricular rate. Please remember that you dont want to slow the ventricular rate in a-fib down if it is the body compansating for another problem such as hypertension, hypovolemia, fever, hypoxia etc.

A lot of people make the mistake of seeing "uncontrolled" a-fib and not looking at the BIG PICTURE, like WHY do they have an uncontrolled rate is it because they are of new onset and not on any meds or is it because they have chronic a-fib, but their body is just trying to compensate for some other problem. Remember someone in a-fib is going to compensate with a fast heart rate just like someone who is in a sinus rhythm, we need to treat the underlying problem.

Sweetooth

[EricEnfermero]

What kind of symptoms did the patient have?

[TooterIA]

Ericenfermo you answered my other post about teh PE's, this is on the same Pt. I copied what I put in the other post about this pt. But since he was pretty much unresponsive he didnt have any Sx
I had a 92 year old Pt come to the ER Fri night with hematochezia X 24 hours. We did a front chest film, Abd series, basic blood work, excluding D-Dimer-he showed no reason to. He was afebrile, denied pain, all vitals normal, lung sounds clear. He had a colonoscopy Sun morning and in recovery he developed uncontrolled A-fib, a new condition for him. He also bottomed his pressures as low as 60 systolic. They did a D-dimer which was positive, and sent him for a spiral CT, which is my small hospital's way of Dx PE's. He has mlutiple diffuse PE's. He is now on Dopamine, 15 L NRBM, uncontrolled A fib in the 150's and barely responsive.
Jessica

[RN1989]

I hope that someone is discussing quality vs quantity of life with his family.

[TooterIA]

I hope that someone is discussing quality vs quantity of life with his family.

I had a lot of conversations with the family, they are waiting on the Pts daughter to come from a 6 hour drive, then they will feel comfortable turning off the meds. It is unfortunate though-I had to tiptoe around the subject to find out exactly what the Dr told this family, the Dr never told them that we are basically keeping him alive. And the pts signed his own DNR a few days prior.
Jessica

[CRNAGAL]

A fib with a rapid ventricular response could most definitely cause hypotension. The rapid rate doesn't allow for adequate filling of the heart chambers during diastole and the "atrial kick" is also lost. The atrial kick accounts for 15-30% of blood ejected from the heart and the elderly rely on that kick even more. The statement that you don't want to slow down the ventricular rate with a fib is false. If that was the case we wouldn't have cardioversion or ACLS. I agree you need to determine and treat the cause, but your goal is to get that rate down to protect the myocardium.

[Sweetooth EMT-P, RN]

Originally Posted by CRNAGAL

A fib with a rapid ventricular response could most definitely cause hypotension. The rapid rate doesn't allow for adequate filling of the heart chambers during diastole and the "atrial kick" is also lost. The atrial kick accounts for 15-30% of blood ejected from the heart and the elderly rely on that kick even more. The statement that you don't want to slow down the ventricular rate with a fib is false. If that was the case we wouldn't have cardioversion or ACLS. I agree you need to determine and treat the cause, but your goal is to get that rate down to protect the myocardium.

I disagree. The patient had multiple other problems that were more than likely causing his hypotension, including multiple PE's and more than likely that was a contributing factor to his uncontrolled rate and in addition he was going to be hypoxic wth the ventalation/perfusion mismatch occuring secondary to his PEs another reason for the fast ventricular response.

When I mentioned that I would not control ventricular rates in a-fib I was specifically mentioning cases like this where the ventricular rate is acting as a compensatory mechanism and not soley because the patient is in a presumably new onset a-fib. I have seen it done over and over again, doctors ordering meds for patient's with uncontrolled rates when the patient's rate is compensating for an underlying problem such as fever, hypovolemia, hypoxia etc... It's like peeing in the ocean it doesn't do anything! All thats done is further decompensation, just what the patient needs.

So I am sorry to disagree with you, but I have had plenty of experience and I have learned from them.

Sweetooth

[Zookeeper3]

Agree with sweet, although I would have switched to a non beta 1 drug that didn't contribute to an accelerated HR like levophed or neo.

OP, while this is a VERY complex issue, afib with RVR or SVT with hypotension..... treating the cause is primary, not knocking down the rate. Could be as simple as dehydration... dopamine causes tachyness with it, could have been too high a dose (clamp the SVR down too much and flow decreases so the HR increases to increase cardiac output.

Basically cardiac output (blood pressure) = stroke volume (volume in the vasculature) X heart rate. With end stage diseases there are many variables, pain( would have increased the meds even with assumed pain), switched to neo or levo, or asked for a fluid bolus, all assuming the temp was normal.

Most times, knocking out the HR, before treating the cause, causes severe HYPOTENSION..... cardiac kick bit all aside. After I've done all that, then I'll treat the afib with RVR... and STILL do all of the above to treat the hypotension caused from the lopressor, cardizem or amio. and dig is still a good option.

so long story short, aside from dig, everything will lower bp, but first make sure that your HR is not high to maintain an adequate BP before you knock it out

pm me if this is confusing

[Zookeeper3]

CRNAgal, yes agree with you, assuming that the increased HR is the true cause of the hypotension. Your multisystem patients present a different picture from your new onset cardiac afibbers who need cardioversion and drips. Where the loss of the atrial kick is new and not tolerated in the elderly., different from a hospice type setting IMHO with my exp. Valid point tho. Different perspective going in, in THIS patient, the hypoxia from the PE's alone caused the accelerated rate, caused irritability and thus the afib, can't tube because the DNR status.

Interesting discussion on the many theorys that plague and challenge our practice. enjoyed it. OP, good question. there's a bunch to learn here.