Atrial Fib. Noninvasive Treatment

pricklypear · Oct 22, 2005

medication

papawjohn · Oct 22, 2005

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

thatoneguy · Oct 22, 2005

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?

papawjohn · Oct 22, 2005

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

thatoneguy · Oct 22, 2005

very nice thanks

Dinith88 · Oct 22, 2005

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.

thatoneguy · Oct 22, 2005

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.

austin heart, BSN, RN · Oct 22, 2005

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.

papawjohn · Oct 22, 2005

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

austin heart, BSN, RN · Oct 22, 2005

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.

zambezi, BSN, RN · Oct 22, 2005

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)