Afib question

[Sugarcoma, RN]

I am an RN of 6 months. Cardiac and Tele are probably my weakest areas. I work on a general surgical floor and had a patient with sustained tachycardia (up to 158) for over an hour. My previous assessment revealed a regular normal heart rate, when I listened to her again it reminded me of listening to a newborns heart. A stat EKG revealed A-fib with RVR, pt. with no hx of a-fib. When it continued, I called a rapid response for assessment.

The team basically walked in and walked out as pt. was stable and converted to NSR shortly. Spent the whole night listening to the tele mon go off as HR jumped up and several times pt. jumped into A-fib again. The docs did nothing, no meds etc. despite the fact that it was happening fairly frequently. When I gave report (to a VERY experienced RN, whom I trust implicity) she told me something needed to be done for this pt. I told her what happened with the rapid and she was also confused.

Here are my questions.

I know that bradycardia is o.k. unless symptomatic, though I still always call docs when it occurs if it sticks around. Same with PVC's, if they are happening frequently. The docs don't exactly appreciate this quality in me (draw lytes, let me know if k needs to be replaced, if not don't call again) With A-fib I learned that pt.s need to be coagulated due to the risk of possibly throwing a clot. Even if this rhythm is not sustained, if they are popping in and out of it regularly for long period of times wouldn't this still be a risk for them?

When do you wait and watch as opposed to calling the doc? If pt has no hx of a-fib and is suddenly a-fib on monitor wouldn't you at least call to report the change? I fear I am developing a reputation as an over-reactor with the residents on our floor. One even told me I was neurotic (in a nice way), this has led to some hesitancy for me to call a doc, but I never let that stop me. I was taught in school if you don't know call someone who does. If I can't get the answer from another RN on the floor, i call a doc.

[Havin' A Party!, ASN, RN]

Your gut is correct. Follow this through. Certainly should be worked up to some extent.

One thing I was looking for was the patient's age, whether the rate was controlled on most of her episodes (the 158 bpm occurrence was certainly not controlled), whether she was symptomatic, the duration of the episodes, any other cardiac related risk factors in her profile, and the patient's desire for intervention.

At the least, presuming all the best answers for minimal treatment to the above questions, this client should be on 81 mg ASA daily (for some anti-platelet protection, with most MDs preferring coumadin for anti-coagulation, as I know you meant).

For example, for seniors (say 60 to 65 yo), with short spells of AFIB (less than several hours), with rates below 125 bpm, who are symptomatic (they don't even realize they're in AFIB, and their lifestyle is no way impacted), with no HTN, CHF, valve issues, cholesterol, diabetes, smoking, etc., AFIB doesn't have to a life-changer by any means.

Good job taking note of the situation for your customer! Keep that going.

Good luck!

[blondy2061h, MSN, RN]

I agree with you on this. I would think that patient would require anticoagulation, unless otherwise contraindicated. I would definitely call the doctor about pretty much any acute change in rhythm. I'm rather surprised no intervention was preformed. This seems like something that would typically get the patient a cardizem drip.

I'm also rather weak on cardiology/telemetry, so hopefully more experienced people will respond soon. edit to add: typed this part before I saw "Havin' a Party's" respond. Thanks for your response!

[Sugarcoma, RN]

Hey guys thanks for the quick replies!

Additional info: 81 years old with a cardiac hx, 2 previous stemi's, CAD, stents x 3. Pt. appeared asymptomatic but was hard to tell. Was just d/c from SICU and extubated that day. Pulse ox was normally low 90's, lungs wheezy and sounded full of "gunk" and had DOE, and that never really changed.

Rate was controlled at times but would then jump up and stay in high 140's. episodes lasted 5-15 minutes with 4 that lasted over an hour. Pt. was sleeping and no LOC changes and appeared quite bothered by me (can't you just let me sleep).

What scared me the most is that in the first 1 1/2 hours that I had pt. feet and legs were expanding before my eyes. In my initial assessment I noted +1 pitting, right before I called the team it was easily +2 and probably closer to +3. Pt. was getting NO fluids at the time and I have NEVER seen anyone blow up that fast. Plus pt got 40 of lasix IVP 2 hours before my receiving them! That was my main reason for calling the rapid.

I will add that pts. edema did not get any worse for the remainder of my shift even when .9 was added (suspected dehydration).

P.S. Havin, thanks for pointing out my error (coagulated), for some reason I cannot edit it.

[Emergency RN]

Sometimes, you just need to resort to brass tacks. Try something along these lines:

"I'm sorry that you need to come back so often for something as ridiculous as an asymptomatic rapid AF, but unfortunately, the protocol here requires that I notify you for the change in rhythm. Further, if you don't respond, then I'm forced to call your senior (the higher resident, or the first's doctor's boss); if your senior also fails to respond, then I'll have to call the attending cardiologist at home. If you don't like that, then I would suggest when you're promoted to director of clinical medicine, please keep those dislikes in mind, and change the god damn policy so that us poor nurses don't have to bother the poor residents with such 'meaningless' things. I mean, it's really a waste of our time too, you know. But until then, when I call, I expect you to be here. Oh, and btw, if you don't show up; don't worry, you can read all about it in the chart; ie. who I called, how many times I called, how many minutes elapsed, what was ordered, et cetera; and have a nice day."

Advice to the OP. Don't worry about it. Stick to your guns. You already have a license, so you need to protect it. A medical resident doesn't have a license yet, and is still in training. Whether he or she passes their training in large part, depends on how they conduct themselves on the floor during their residency. Your job is to protect the patient, not the medical resident. Frankly, their convenience or work load isn't even on my radar. Sometimes, these "doctors" forget that we don't work for them. Sure, we will follow their medical orders, but we work for the hospital in delivery of care to the hospital's patients. Ultimately, my employer makes the rules. If the rules are to call the MD for a rhythm change, then that's what I will do; the resident's likes or dislikes are not my concern. We are not there to make friends; just do your jobs. Period.

Further, from your follow up post, the patient sounds like a train wreck to being with. Someone with such an extensive history, in new onset Rapid AF, really belongs back in a telemetry setting, regardless if they were asymptomatic or not, IMHO.

[HouTx, BSN, MSN, EdD]

I agree with previous poster - good for you for following established protocol for Rapid Response.

At that age, afib may be completely benign, but you never know. It can sometimes be a very early sign of CHF - as the atria begin to stretch with increased volume, they become irritable and trigger the fib. I have had patients that flip into afib when they are completely recumbent... it went away with elev HOB.

[diane227, LPN, RN]

What I wonder here is why this patient is developing A-fib? In my experience, patients who show the pattern of going in and out of A-fib eventually transition into A-fib as their primary rhythm. You certainly do have to worry about the patient throwing a clot but you also have to worry about the drop in cardiac output because when a patient goes into A-fib, no matter what the vent. response rate, you lose atrial kick, which accounts for about 30% of your cardiac output. If your patient already has a low EF, your overall perfusion can be greatly affected. This patient, given this history, certainly warrants more MD intervention.

[Virgo_RN, BSN, RN]

For Paroxysmal A-Fib (AF that self terminates) in an asymptomatic patient, the doctor isn't likely to "do" anything. It really is sort of a "watch and wait" kind of thing. I'm guessing that this patient was probably already anticoagulated with a low molecular weight heparin following their surgery. At this point, starting them on Coumadin would be unnecessary. This patient mostly just needs a cardiology consult. I'm guessing with that cardiac history that the patient has a cardiologist, and it would behoove the attending physician to contact them about this patient.

Addressing the underlying cause, if known, is often the best strategy for PAF. Aside from the stress of surgery, the fluid shifts you described could have been a part of the picture, which it sounds like was being addressed. So it's not as if the doctor didn't do anything at all. By giving supportive care to get this person recovered from the many insults to the body caused by surgery, the doctor is addressing the A-Fib.

You were correct to call the physician with the first episode, and the physician should have given you some parameters to follow for repeat episodes, such as to call the physician if the patient remains in AF for longer than a specific period of time, and/or if the patient becomes symptomatic.

Be sure to document the frequency and duration of episodes, and your observations of the patient's condition during the episodes. As for rhythm strips, the cardiologists where I worked preferred to have just the start of the arrhythmia and the termination of it. They didn't need to see the whole thing.

Definitely call if you notice any change in patient condition.

What cheeses me off here is NOT that the doctor did not "do anything", but that he did not explain to you WHY he didn't do anything. This sets you up to worry about the patient and to doubt yourself as a nurse. I really wish doctors would explain things like this to nurses, as a courtesy.

[Virgo_RN, BSN, RN]

Edited to add: I agree with a previous poster that this patient has bought himself a tele bed.

[respectall]

This pt needs cardiology consult ASAP to better handle his arrythmia.

[martymoose, BSN, RN]

pt was symptomatic with the periph edema and gunky lungs, low sats, Doe, etc. Seriously- what were they waiting for? For her to go into complete heart failure?Flash pulmonary edema? esp with her hx? This is one of those times, I "eat it", and call the doc back until we get somewhere productive- ie- resolution of symptoms- its not normal to have gunky lungs, pitting edema, doe, sustained bursts of hr in the 150's. The only time I have ever seen anyone tolerate that was a guy in his 30's , and it may have been svt due to hyperthyroid. This pt of yours sounded very frail.Yes maybe she was stable when you called the doc, but if that rate was to continue enough times, she wasnt going to stay stable, esp with that hx. Cant believe they didnt get a cards consult for cardizem gtt and transfer to cards floor.

Anyhow, the point is- you are not over reacting- you are doing what's right, and a good job for being so observant with your pt( even if you irritated her thruout the night) Sometimes we have to argue(oops , i mean, collaborate) with docs- but were doing it for the pt- and document everything- " called dr blabla who is informed of pt condion of bla bla, . No new orders- continuing to monitor pt". You did your part, but dont ever be afraid to call a doc. We should be more afraid of NOT calling a doc.

I hope your management was also made aware of the 1:1 time you had with this patient's condition.

Anyway- youre doing a good job. keep up the good work.

[respectall]

If the pt is status post op, there are many possible etiology to his afib.

1. fluid vol deficit or overload

2. electrolyte embalance

3. pulmonary emboli

4. sepsis

5. substance withdrawal ( etoh, tobacco)

If all of the above have been corrected and the problem persist then It is a circuit problem caused by an ectopic pacer cell. Electrophysiology study might be necessary or simply start pt on beta blocker or amiodarone po, no need for drip unless pt remains in UCAFIB without conversion.