Intervention for pt with a-fib/a-flutter who’s bradying down.

MunoRN, RN · Dec 13, 2020

Generally with a slow A-fib or flutter the problem is that AV node is over-blocked / under-conductive.

Dopamine increases the rate of the sinus node as well as ectopic foci in the atria, this won't help if the atrial rate (either from the sinus node or ectopic rate) is already plenty high and the beats just aren't making it through the junction.

A vagoplegic like atropine would likely increase the ventricular rate by letting more of the atrial impulses through, but this is sort of playing with fire since with A-fib or flutter you want the AV node to block most of the impulses coming from the atria. A slow A-flutter with a ventricular rate of 40 is potentially problematic, but then again so is A-flutter with 1:1 conduction where the flutter rate is 200 bpm.

Typically your best bet is pacing, either transcutaneous at rate and output no more than the bare minimum required, some fentanyl / versed, and quick placement of a transvenous or micra.

Anonymous666 · Dec 13, 2020

9 hours ago, MunoRN said:

Generally with a slow A-fib or flutter the problem is that AV node is over-blocked / under-conductive.

Dopamine increases the rate of the sinus node as well as ectopic foci in the atria, this won't help if the atrial rate (either from the sinus node or ectopic rate) is already plenty high and the beats just aren't making it through the junction.

A vagoplegic like atropine would likely increase the ventricular rate by letting more of the atrial impulses through, but this is sort of playing with fire since with A-fib or flutter you want the AV node to block most of the impulses coming from the atria. A slow A-flutter with a ventricular rate of 40 is potentially problematic, but then again so is A-flutter with 1:1 conduction where the flutter rate is 200 bpm.

Typically your best bet is pacing, either transcutaneous at rate and output no more than the bare minimum required, some fentanyl / versed, and quick placement of a transvenous or micra.

Thanks, MunoRN. That makes a lot of sense.

So with a rate sustained in the 40’s and even 30’s, your best intervention would be to grab the crash cart and try some transcutaneous pacing.

How would one go about doing this? Feel free to just tell me to Google whatever. Hook the pt up to the crash cart with the two pads, select “pacing” and your rate, and just increase the current until it captures?

Do you need to connect other leads? Do all crash carts have these other leads?

And I’m assuming a situation where this is being set up while someone else is paging a doc for orders.

Anonymous666 · Dec 13, 2020

1 hour ago, Anonymous666 said:

Thanks, MunoRN. That makes a lot of sense.

So with a rate sustained in the 40’s and even 30’s, your best intervention would be to grab the crash cart and try some transcutaneous pacing.

How would one go about doing this? Feel free to just tell me to Google whatever. Hook the pt up to the crash cart with the two pads, select “pacing” and your rate, and just increase the current until it captures?

Do you need to connect other leads? Do all crash carts have these other leads?

And I’m assuming a situation where this is being set up while someone else is paging a doc for orders.

I just watched some Youtube videos on how to get this set up. I’m assuming all crash cart monitors come with the 3 ecg lines.

chare · Dec 13, 2020

4 hours ago, Anonymous666 said:

[...]

How would one go about doing this? Feel free to just tell me to Google whatever. Hook the pt up to the crash cart with the two pads, select “pacing” and your rate, and just increase the current until it captures?

Do you need to connect other leads? Do all crash carts have these other leads?

[...]

Google and Youtube, if you are viewing reputable sites, are good sources, and can be useful for providing a basic understanding. However, as there is some variation between manufacturers, as well models from the same manufacturer, you should schedule some time with your educator so he or she can go over this with you.

Best wishes.

MunoRN, RN · Dec 13, 2020

7 hours ago, Anonymous666 said:

Thanks, MunoRN. That makes a lot of sense.

So with a rate sustained in the 40’s and even 30’s, your best intervention would be to grab the crash cart and try some transcutaneous pacing.

How would one go about doing this? Feel free to just tell me to Google whatever. Hook the pt up to the crash cart with the two pads, select “pacing” and your rate, and just increase the current until it captures?

Do you need to connect other leads? Do all crash carts have these other leads?

And I’m assuming a situation where this is being set up while someone else is paging a doc for orders.

I wouldn't pace just based on the heart rate, many people can tolerate a sustained HR of 40's and even 30's just fine, I wouldn't get them up and take them for a walk at that rate, but they don't necessarily require pacing. Transcutaneous pacing should be reserved for when pacing is necessary due to acutely symptomatic bradycardia (unconsciousness for instance).

As Chare pointed out, I would reach out to your educators as the method varies by manufacturer and the equipment on hand.

As a general rule though, defib/pacers can asynchronously pace without any additional leads attached, which is fine for asystole but can be problematic if it's not able to sense the patient's intrinsic rhythm, potentially pacing late in the T wave and putting them into a ventricular arrhythmia.

There are pads that include built-in ekg leads, such as the Zoll 'triangle' pads with CPR button. Even educators will sometimes incorrectly assume this is all you need to pace with sensing. To pace, there should be a separate set of 3 leads, where those are kept will usually be facility-specific. On a Zoll the EKG portion of the main cable plugs into the back of the device, you would unplug that and plug in the separate 3 lead into the same spot. When you switch to the "pacer" function it starts with an output of 0, to pace you turn up the output dial, typically requiring multiple turns to get up to an output that captures.

This should only be a very short term fix, while the MD is being notified and better pacing options are being pursued.

nursej22, MSN, RN · Dec 30, 2020

FWIW, I had atrial flutter with a rate of 40 and waited 2 months for an ablation/pacemaker. My symptoms were fatigue and dyspnea on sl. exertion. And I have had hospitalized patients in the 30s, that were asymptomatic while on bedrest. We kept the pads on the patient, and the cart in the room just in case, while they were awaiting a pacermaker implant. Symptomatic patients went to ICU for transvenous pacing.

marienm, RN, CCRN · Feb 20, 2021

I love reading Muno's posts and I always learn a lot! To this one I want to add, though, check a full set of electrolytes and review any known medication history. I had a memorable experience with a patient whose potassium was 8 following succinylcholine for intubation. HR was low 50's a-fib, BP was okay. We did all the normal things for hyperkalemia (insulin/dextrose/albuterol/kayexalate/calcium via IV). After the calcium (and doubtless the insulin was beginning to work as well to lower the K) the HR was 120's. Still a-fib (a known diagnosis for the patient) but it looked much better than low 50s!

amoLucia · Feb 22, 2021

On ‎2‎/‎20‎/‎2021 at 10:27 AM, marienm, RN, CCRN said:

I love reading Muno's posts and I always learn a lot!

I agree! Altho he's usually way past my total comprehension level!

But then I've retired from LTC for some time and have lost some brain cells (really)

There are others who explain things very well. I love when I learn from them.

martymoose, BSN, RN · Feb 25, 2021

Our Pa's told us afib can tolerate pauses of 6 seconds ! only a fib tho. Not sure how much I want to believe that one. I had a gal have a pause of 7 seconds ; I went in to wake her up and ask her if she felt OK. Her answer was, " yes, I was having the best dream ever" Not on my watch lady, LOL!

My first thought on this forum question was set up zoll/pads ready to go if patient becomes symptomatic. We are always told "if pt. is symptomatic" no matter how slow the rate is. I've had some patients with a rate of 28-32 , and they're perfectly fine( well ,we keep 'em in bed tho")

Third degree block is whole other story !