Atrial Fib. Noninvasive Treatment

Specialties CCU

Published

Hi Everyone Just Wondering What Are Some Non Invasive Treatments For A. Fib.?

Specializes in CCU/CVU/ICU.
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.

AustinHeart,

Thats unusual (and dangerous) the way you're describing a-fib cardioversions in ER. The biggest reason for that not being good medicine is because in elective cardioversion for a-fib the pt is at big risk for embolism and should be adequately anti-coagulated first. An echo is obtained before-hand to r/o thrombus, etc. Also, as a few have stated, meds are vital to keep the AF from recurring (which, unfortunately, occurs alot w/af cardioversions).

If someone walks into the ER with A-fib (especially new a-fib), a work-up is in order and the patient gets (should get!)admitted, buys a cardiologist, etc. And if someone walks into the ER with chronic a-fib and gets shocked, they're VERY likely to relapse...especially if (as you say) they're taken off dig., no drugs, etc.

Meds are always the first choice (rate control, etc.)...and then if pt remains symptomatic a cardioversion may then be in order...under controlled conditions...

You may not have seen it (yet), but when one of these "3-4 af cardioversions a day in the ER" throws a clot, dies of ventricular standstill (from cardioversion), or otherwise does poorly, i'm betting your er will change its ways. Until then, your er is acting dangerously and is potentially setting itself up for bad things.

Lastly, if the rate is way up and patient is unstable, of course your hands may be tied and emergent cardioversion would be neccessary. However, an unstable a-fib refractory to meds is the exception (big exception) rather than the norm. It's too bad that its not as easy as 'shock em and send them home'...

(my entire post may be wrong if you were meaning your hospital schedules elective cardioversions for a-fib...which are then done in er (weird??- slow er??) rather than in an ep-lab, CCU, CardiacIMCU, etc. These folks would then surely have had work-ups, been anticoagulated, etc.)

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Specializes in Education, FP, LNC, Forensics, ED, OB.
AustinHeart,

Thats unusual (and dangerous) the way you're describing a-fib cardioversions in ER. The biggest reason for that not being good medicine is because in elective cardioversion for a-fib the pt is at big risk for embolism and should be adequately anti-coagulated first. An echo is obtained before-hand to r/o thrombus, etc. Also, as a few have stated, meds are vital to keep the AF from recurring (which, unfortunately, occurs alot w/af cardioversions).

If someone walks into the ER with A-fib (especially new a-fib), a work-up is in order and the patient gets (should get!)admitted, buys a cardiologist, etc. And if someone walks into the ER with chronic a-fib and gets shocked, they're VERY likely to relapse...especially if (as you say) they're taken off dig., no drugs, etc.

Meds are always the first choice (rate control, etc.)...and then if pt remains symptomatic a cardioversion may then be in order...under controlled conditions...

You may not have seen it (yet), but when one of these "3-4 af cardioversions a day in the ER" throws a clot, dies of ventricular standstill (from cardioversion), or otherwise does poorly, i'm betting your er will change its ways. Until then, your er is acting dangerously and is potentially setting itself up for bad things.

Lastly, if the rate is way up and patient is unstable, of course your hands may be tied and emergent cardioversion would be neccessary. However, an unstable a-fib refractory to meds is the exception (big exception) rather than the norm. It's too bad that its not as easy as 'shock em and send them home'...

(my entire post may be wrong if you were meaning your hospital schedules elective cardioversions for a-fib...which are then done in er (weird??- slow er??) rather than in an ep-lab, CCU, CardiacIMCU, etc. These folks would then surely have had work-ups, been anticoagulated, etc.)

:yeahthat:

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hi siri, nice to see you again.

humm, acls algorithm protocol states if unstable hemodynamically with signs and symptom and a rate of 150 or greater do immediate cardioversion. they maybe shocking v-tach in his ER. i dont know but if A. fib. is under 48 hours duration and unstable do cardioversion first, with no anticoagulate. per acls protocol. here is something else they say ,"inexperenced acls providers sometimes misinterpit this approach and think they should completely forego giving antiarrhythmics in unstable patients with a pulse. delay is the issue. when patients with symptomatic tachycardia are able to maintain a pulse and measurable blood pressure, the clinician can perform the cardioversion in a controlled manner". basiclly i think they are saying meds take time to work and time is not on our side for a patient that is symptomatic. does this sound right?

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Specializes in ICUs, Tele, etc..
hi siri, nice to see you again.

humm, acls algorithm protocol states if unstable hemodynamically with signs and symptom and a rate of 150 or greater do immediate cardioversion. they maybe shocking v-tach in his ER. i dont know but if A. fib. is under 48 hours duration and unstable do cardioversion first, with no anticoagulate. per acls protocol.

Hello...I think that's why they're saying that doing cardioversion in that particular ER without anticoagulation could be dangerous because when a patient comes in for rapid afib, you don't know when the patient developed it.

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yeah i see that. but the protocol says do this for any unstable tachycardia. the time is only talked about in the stable A. fib. this will be a good question for my class today.

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Specializes in ICU.
AustinHeart,

Thats unusual (and dangerous) the way you're describing a-fib cardioversions in ER. The biggest reason for that not being good medicine is because in elective cardioversion for a-fib the pt is at big risk for embolism and should be adequately anti-coagulated first. An echo is obtained before-hand to r/o thrombus, etc. Also, as a few have stated, meds are vital to keep the AF from recurring (which, unfortunately, occurs alot w/af cardioversions).

If someone walks into the ER with A-fib (especially new a-fib), a work-up is in order and the patient gets (should get!)admitted, buys a cardiologist, etc. And if someone walks into the ER with chronic a-fib and gets shocked, they're VERY likely to relapse...especially if (as you say) they're taken off dig., no drugs, etc.

Meds are always the first choice (rate control, etc.)...and then if pt remains symptomatic a cardioversion may then be in order...under controlled conditions...

You may not have seen it (yet), but when one of these "3-4 af cardioversions a day in the ER" throws a clot, dies of ventricular standstill (from cardioversion), or otherwise does poorly, i'm betting your er will change its ways. Until then, your er is acting dangerously and is potentially setting itself up for bad things.

Lastly, if the rate is way up and patient is unstable, of course your hands may be tied and emergent cardioversion would be neccessary. However, an unstable a-fib refractory to meds is the exception (big exception) rather than the norm. It's too bad that its not as easy as 'shock em and send them home'...

(my entire post may be wrong if you were meaning your hospital schedules elective cardioversions for a-fib...which are then done in er (weird??- slow er??) rather than in an ep-lab, CCU, CardiacIMCU, etc. These folks would then surely have had work-ups, been anticoagulated, etc.)

Yup, it is a slower ER. And as I said, I only work weekends when day patient is not open and the majority of the cardioversions are elective. It is a small Dr. vested hospital and most of the patients that come in are patients of the cardiologist (30+ doctors) that have their office in house. I also was assuming that people here would know that appropriate cardiac work up would be done prior to cardioversion. It is not as if they walk in and we cardiovert. Most of these people are already on coumadin and are being closely monitored in the coumadin clinic. Then Pt/INR is always checked before cardioversion. If any possibility of patient being under coagulated a TEE is done prior to the cardioversion. Are the cardioversions in your facility always done in EP lab or an ICU setting? They are also done quiet frequently on our tele floor. I also never said that patients where totally taken off drugs either. Dig is just not the drug of choice here.

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ok i found out. its the doc's call. from a nurses perspective we should ready for cardiovert as per acls protocol. if A. fib. and BPM is 150 or higher and symptomatic than goto cardiovert. and yes the doc should do a TEE prior to converting but it would not be wrong to go straight to cardiovert. its one of those many grey areas. its also listed in the cardioversion algorithm.

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Specializes in CCU/CVU/ICU.
Yup, it is a slower ER. And as I said, I only work weekends when day patient is not open and the majority of the cardioversions are elective. It is a small Dr. vested hospital and most of the patients that come in are patients of the cardiologist (30+ doctors) that have their office in house. I also was assuming that people here would know that appropriate cardiac work up would be done prior to cardioversion. It is not as if they walk in and we cardiovert. Most of these people are already on coumadin and are being closely monitored in the coumadin clinic. Then Pt/INR is always checked before cardioversion. If any possibility of patient being under coagulated a TEE is done prior to the cardioversion. Are the cardioversions in your facility always done in EP lab or an ICU setting? They are also done quiet frequently on our tele floor. I also never said that patients where totally taken off drugs either. Dig is just not the drug of choice here.

OK..i got ya. I think what threw me was the elective cardioversions being done 'in er'...'on weekends'...if 'ep doc is on call' just sounded kinda strange.

And no...you're correct. At my place of employement we have some cardiologists who'll do them on IMCU/tele floor...but the majority now are done in EP lab. These patients are not in our ICU. ( btw, we do them @ bedside in ICU...they're just not the routine, scheduled ones ;) )

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Specializes in CCU/CVU/ICU.
:yeahthat:

Holy crap. I just fell out of my chair.

Siri, are you posting in the right thread? :specs:

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Specializes in Education, FP, LNC, Forensics, ED, OB.
holy crap. i just fell out of my chair.

siri, are you posting in the right thread? :specs:

well, you know, dinith.....occasionally you are correct. :roll

and, besides, you cannot be all bad.......after all...

you are from chicago territory and......

:clown: the sox won again!!!! woot!!!!!!!!!!

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There is a need to be careful even with unstable A-fib coming in to the ER or anywhere if the onset is unknown. After 48 hours it is advisable to slow the heart rate but NOT to sinus rythm. If a clot has formed, this could create too strong of a contraction and throw that sucker. Slightly tachy is preferred until anticoagulation. Visual confirmation of no clots via echo study is a plus.

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Hey Y'all

Was just droppin' by and happened to re-read the OriginalPost. 'what are non-invasive treatments' for AF.

Humm.....if the OP is still hanging around, were you implying that there's INVASIVE treatments? Were you thinking of like the EP Lab.

Just happened to notice, was curious.

Papaw John

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