A fib in the 40's??

KBICU · Sep 20, 2012

Yes I have a few times...controlled a fib is a HR below 100 but thats awesome she converted.

Morganalefey · Sep 20, 2012

I've seen it below 100, but never as low as the 40's!

Just curious, how did they treat it? I'd be hesitant to put someone w/such a low HR on a cardizem or amiodarone drip.

DuluthMike · Sep 20, 2012

I recently had a redo sternotomy endocarditis/sepsis. Afib @70's and dwindled to 40's over my shift. SVR 400's. Midlevel who ordered Amio and Norepi. No pacing wires. Freq conversion to Vfib. Awesome fun night.

nicolein · Sep 20, 2012

I've seen a slow Afib in the 40s. I think the pt was dig toxin!!

BelgianRN · Sep 21, 2012

I've seen it below 100, but never as low as the 40's!
Just curious, how did they treat it? I'd be hesitant to put someone w/such a low HR on a cardizem or amiodarone drip.

As a general rule you don't want to convert such a slow Afib you run the risk of going into cardiac arrest. As a PP stated such a slow Afib is usually secondary to excessive rate control (e.g. digoxin toxicity, beta blocker effect). It can also be due to a conduction abnormality (e.g. Afib with third degree AV block and an escape rhytm). In both circumstances you don't want to give any medication that decreases the ventricular response rate and run the risk of ending up with nothing left :)

On top of that when treating an Afib you have to consider the benefit of converting. Comparing a slow Afib in the 40s - 50s to a sinus rhythm in the 40s-50s has very minimal differences in terms of hemodynamic consequences. At such a slow ventricular rate the ventricles have plenty of time to fill up already and the atrial kick from the sinus rhythm will add little or nothing of value to the filling of the ventricles.

turnforthenurse, MSN, NP · Sep 21, 2012

I have seen Afib that slow. In fact, when my patient was sleeping his HR suddenly dropped to 31 :eek: (still Afib)...I ran in there and he was asleep. Woke him up, no symptoms, all other VS WNL. Notified the hospitalist on call but my assessment was benign. I just kept an eye on him. Nothing happened.

RnfromUK · Sep 21, 2012

I work with an Electrophysiologist and we see afib at a wide range of speeds from over 200 (Yikes!) to as low as 40's (I think 44 was the slowest I have seen). As long as they are asymptomatic then you dont want to mess around with trying to convert them. As was said, slow Afib is better than nothing at all and Afib below 100 bpm is considered controlled. :)

Morganalefey · Sep 21, 2012

Thank you guys so much! The amount of knowledge and experience here is amazing. I will NOT forget this.

I made my story short b/c the rest of it wasn't relevant to my question, but now it is.

Like I said, lady was a direct admit. She had seen the dr several hours earlier in the day where her EKG was A fib in the 40's. She got to me, I called him to let him know she was here. He tells me he will put orders in (in house, but not on my unit). Admissions nurse does her thing, aide takes vitals and hooks her up to tele and I do my head to toe. I go check orders and he's ordered a heparin drip and an amiodarone drip (I don't remember the dosage). I think: "HUH. I've d/c'd people off this when their HR is in the 60's...hmmm..." I pull her tele strips which look sinus brady to me. I ask the other nurses, and call the monitor techs. Yup, everyone agrees, sinus brady. I order an EKG. Sinus brady.

So of course, I call the doc back and he d'c's the amiodarone but wants to continue the heparin.

But it is frightening to me that he would put a pt w/a HR in the 40's on an amiodarone drip:eek:

A few weeks ago we had a nurse float to us from the ICU, she was relieving me, and I was giving her report about a pt who was this particular dr's. She said "Dr So-and-so isn't like a real dr. You have to tell him what to do." Id idn't say anything, I've been a nurse for a year, and don't for a second think I know more then a cardiologist who has been in practice most, if not all, of my life. But this experience has me very nervous about the next time I have one of his pt's.

Thank you guys again for your input. Like I said, I will not ever forget this crucially important information.

TeresaRenee3 · Nov 14, 2012

Sick sinus syndrome... The natural pacemaker no longer is able to control rate. Seen this many times. Chronic afib with frequent RVR regardless of meds is admitted and the HR is 50s and below. They "win" a PPM :)

martymoose, BSN, RN · Dec 2, 2012

I see it fairly often- 40's. usually they do buy themselves a pacer

RainyDayParade22, BSN, RN · Dec 14, 2012

I admitted an 80 year old patient who had chronic afib, and came in because he was feeling "tired" and "not right". His heart rate was in the 20's, and it was afib! Surprisingly he was actually tolerating it quite well (he must have had great cardiac output!), but just seeing a HR in the 20's makes us nurses nervous. Needless to say, he earned himself a pacemaker.