Different strokes for different folks. Some,management strategies opt for rate control ithers are more heavy on rhythm control.
For the rate control folks pacemakers are great for when you wanna ablate the AV Node (cause a 3rd degres Block) and just pace the ventricle.
For Rhythm control Pacemakers are great at fighting Heart Failure and keeping AFIB from returning.
Here are some things to remember about AFib (general info):
1. Most pacemakers have 'mode switching' features these days. That means when the afib starts only the ventricular component paces.
2. AFib as a disease is part of the same pathologic process that leads to AV blocks and Sick Sinus Syndrome. The majority of the AFib cases you see will likely have one of these other diagnosis. Thus many if these patients will already have pacemakers for some other indication when they start developing a noteworthy AFib burden.
3. Once a patient goes into AFib there pacemaker can't do anything about it. The only treatments from there are drugs, cardioversion or simply letting the patient break on their own.
4. AFib Ablation is the LAST line of defense. The procedure is transseptal and has a high rate of complication and failure. Afib ablation are also the most taxing procedures in terms of time and resources. They take anywhere from 4- 12 hours to complete and require almost twice the normal staff. 30% of procedures will have at least some form of complication. 30% of patients will ses the procedure fail and afib return in the next 10 years.
5. Once a patient is converted out of AFib an atrial pacemaker may assist in keeping the region responsible for the AFib suppressed for a longer period.
6. Frequent PAC's are associated with an impending episode of AFib and can give a rough estimate of how long a conversion will hold.
7. Best drugs to manage AFib are (in order of aggression, and often risk):
-Class 3 Anti-Arrhythmics:
Amiodorone (high success rate, but risk of toxicity)
Ibutilide (IV preparation only, very expensive, short supply but the only drug that's been studied and proven to be more effective than Amio. This drug also carries a lower risk of complication. It is the drug of choice in the EP lab.),
Sotalol (oral preparations available, common in most hospitals, less risky than Amio. Drug of choice to accompany a synchronized cardioversion)
- Class 1c Antiarrhythmics
Speaking from anecdotal experience class 1c seems to work better at controlling both AFib in addition to Ventricular ectopy. Propafenone seems to be a good selection for AFib, but Flecainide works as well. Flecainide would probably be best for PVC control of the two.
-Calcium Channel Blockers
Diltiazem and Verapamil.. Both very popular choices in Afib management. Diltiazem is the big winner here, common, affordable, patient can take it home.
The tic tacs of antiarrhythmics. Appropriate for patients with low burdens or who need Beta Blockers to treat other issues such as hypertension anyways.
8. Thrombus and Stroke is a big risk for these patients. Most cardioversions, if not for immediately life threatening indications, will get a Trans-Esophageal echo prior to conversion. The TEE is vastly superior to the transthroacic ultrasound at visualizing the atrial appendages, which are the primary location where these thrombus like to hide. Exceptions to the TEE may exist in patients who only recently went into AFib on an inpatient unit, or those with aggressive anticoagulation stategies (e.g. INR over 1.8 for a long period). Local protocol will likely dictate the best course here.
9. Patients who do not wish to maintain their present anticoagulation strategy, have contraindications or in whom antithrombotic appraches fail may elect to have a 'Watchman' device implanted. Watchmans are basically just 'screens' or filters that sit in the appendage and prevent clots from embolising into circulation.
10. Afib and Aflutter are often confused. Having a regular rhythm doesnt really matter.. What if Aflutter has variable conduction? What if the variation is only 30 ms?
The easiest way to identify the difference is to look at lead V1. Measure the wave you see there, is it LESS than 200ms or .20 (5 small/1 big box)? If so, your patient is in AFib.
11. Proper pad pacement for a cardioversion for all ages is anterior-posterior (pediatric placement standard).
First, shave the areas I am about to describe. Clean the surface well with alchohol (not chlorohexidine or iodine) prior to pad application.
Place 1 pad on the anterior surface of the chest, just barely to the right of the sternum (sternal border). Place the other pad on the back just to the LEFT of the spine. It should not be sitting over the shoulder blade.. Avoid contact with thick bones as much as you can.
Look at your patient, do they look Small/Medium, Large or Huge? Set the defib to 100, 150 of 200 accordingly. Sync to the R Wave. Have someone place a pillow on top of the anterior pad and apply about 25 pounds of force (push hard). Shock. If unsuccessful, step up to 150 for small or medium folks, consider augmenting with Sotalol or Ibutilide for Large guys before stepping up to 200. Massive guys should get chemical augmentation jf they have not already. A second attempt at 200 can be tried. After that you will have to apply another set of pads and use a second monitor to deliver 2 shocks simultaneously. This all assumes biphasic shocks are the standard.
12. Scariest Afib ablation complication is pulmonary venous stenosis. Always watch your pt carefully when recovering a patient post Afib Ablation.
13. Afib is associated with CHF as well. Many Afib patients will need biventricular or 3 lead pacemakers to maintain ventricular synchrony.
14. Most Afib with RvR isn't an immediate life threat, however there is 1 exception:
Afib in patients with WPW or accessory pathways is an inmediate, life threatening emergency. If your patient had delta waves, and they develop AFib don't hesitate to call a Code Blue, a Rapid Response or the doctors personal phone or duty phone as the situation allows.
Without the AV Node to block excess impulses theres a chance that the afib will conduct directly to the ventricles. Afib conducting to ventricles without delay = Vfib =death. Its extremely serious and needs attention.
In terms of pacing, I saw something mentioned in this thread that reminded me of some more pearls:
If you suspect issues with pacing it's probably a good idea to just go ahead and draw up:
2. Blood Gas
Drugs that improve thresholds for both pacing and defib/cardioversion would include Catecholamines (Epi/Norepi) and Corticosteroids (Cortisol/Solu-medrol). Never hearts to recommend these things to the doc if you guys are at a loss.