Rapid Afib

That sucks you were so busy!. And yes, it seems you did everything right and had your stuff in order. Amio may have been the next step i suppose, or perhaps some beta-blockers. The biggest thing someone can come away with from this post is that you never panicked(sp?). Rates like that probably had all the nurses on your floor nervous...walking by the monitor and making comments *("wow...whatcha doin for that rate/...cardizaem aint workin...that guy needs to be in the unit"...etc. ad nauseum). If he wasn't symptomatic with that rate then there was really no reason to sweat it. And like you said he was a chronic a-fibber. Perhaps he had an undelying issue (you said his stomach needed pumped) driving the rates. Once that issue gets resolved his rates may come down all on their own...

Based on the info provided, it seems to me you did everything right... possibly could have taken the cardizem up a little quicker or higher (our tele unit limit for cardizem is 20mg/hr) but that doesn't sound like it would have done much.

Agree with Dinith regarding a beta blocker- sometimes 5mg iv lopressor q5 minutes x3 works well (and often doesn't even require the third dose). Since the doc ordered dig, I'm surprised he/she didn't order a follow-up dose of that as well... Amio would have been a good choice as well...

How old was the pt? Underlying cardiac issues? Renal status? Pulmonary status? Current EKG/enzymes?

You can usually fix BP issues with a fluid bolus (or 3 )...

Thanks you guys for your reassurance and suggestions. It turned out that they tried dig again, and then lopressor x 3. The guy apparently was refractory to diltiazem!

Refractory to cardizem? Explain that one please, I haven't heard it before. Do you just mean that it has the opposite effect, or no effect?

I've had two patients who didn't convert with cardizem. One didn't convert, didn't slow down much either, with cardizem, digoxin IV, Lopressor IV, etc. Then he had a massive GI bleed and died the next day. The other was chronic in the 100's to 130's and had been intolerant of amiodarone so that wasn't a problem. She would slow down to 90's on cardizem drip but get up in the 130's and be symptomatic with her BP on PO cardizem. And it didn't help that she knew all of this and would worry about it nonstop.

But I hadn't heard anyone say these two were "refractory" to it. Interesting.

Hi Zac,

It sounds like you acted appropriately. In my experience, cardizem works fairly quickly and is effective in most cases. However, we just had a pt the other night from ER with an amiodorone drip for UCAF. When I asked why, they said amio is what worked for this pt in the past. Sure enough, the pt had converted to SR within an hour.

My question for you is.... why was the cardizem not initiated on your pt in the ER? I would think that a HR of 150-180 would take priority over complaints of nausea. I would consider this pt unstable and don't think I would have accepted him. They have the drugs and doctor readily available in ER. In my hospital, ER is responsible for initial treatment and this pt would require 1:1 care with titration which is not doable on a busy telemetry unit. Just curious.

berna, i work tele step-down. we consistently get the patients running afib rvr and start the dilt. gtts. i have gotten them from er and as transfers.

if they are asymptomatic they do not go to the unit. so long as the vitals are holding out we get them first. we just had one two days ago who was systolic in the 70s running 170 hr. we were running fluid boluses and titrating gtt at the same time. was not a pretty sight at all.

anyway, it is standard for our floor to start the drips. but i agree with you. it would be nice if er would start them but ......

So just out of curiosity, how were his Lytes?

I work in ER and am surprised that a pt would get sent to you with HR that high without the gtt getting started in the ER...I guess all hospitals are different.

Just curious as to why he only got a 10mg bolus? We give .25mg/kg bolus, wait 15 min and give another .35mg/kg bolus before starting the gtt; in my experience the two boluses are what generally bring the HR down and then the gtt maintains it. I know everybody responds differently and the larger boluses may not have made a difference either...but that's how our protocol is written and usually works very well.

One would think that if they expected you to initiate the drips, they could at least allow you to stock the drug in your department.

one would think that if they expected you to initiate the drips, they could at least allow you to stock the drug in your department.

i totally agree with you. we did have them on our floor until about four months ago. it was decided that to be in accordance with patient safety standards that all meds must come up from the pharmacy after a doctor's order has been faxed to them.( we do not even have stock tylenol now). thus the wait for the meds.

sad but true and one day it will cost someone their life.

i totally agree with you. we did have them on our floor until about four months ago. it was decided that to be in accordance with patient safety standards that all meds must come up from the pharmacy after a doctor's order has been faxed to them.( we do not even have stock tylenol now). thus the wait for the meds.

sad but true and one day it will cost someone their life.

this would infuriate me. i can think of numerous times i've gone to our pyxis that has meds and had to override to obtain meds based on verbal stat orders. for example- i had to get dopamine the other night. i've had to get lasix for flash pulmonary edema, haldol to calm a pt who required 6 people to hold her down, iv lopressor... i couldn't imagine having to wait for a fax to pharmacy, then have the med sent/delivered before giving it. i'd like to think i didn't waste my time getting a bsn only to be treated like a child with excessive safety measures. as an educated adult, i'd like to be treated as one.

Thanks you guys for your reassurance and suggestions. It turned out that they tried dig again, and then lopressor x 3. The guy apparently was refractory to diltiazem!

If I remember correctly, you posted this patient has a history of AFib w/RVR, and he was asymptomatic. What antiarrhythmic meds has he taken in the past regards to his AFib HX? Calcium Channel Blockers, such as Diltiazem, usually are an excellent measure to slow the ventricular rate in AFib. However, looks like your patient's cells were not very receptive to Diltiazem. I'm curious as to why Amiodarone was not considered D/T its ability to decrease automaticity rate of ventricular ectopic foci, therefore useful for its anti-fibrillatory actions. However, Amiodarone may be proarrhythmic R/T its ability to prolong the QT interval. Plus, liver enzymes must be watched with Ami's long half-life. Another consideration would be Rythmol, a Class IC medication. However, this, too, can have proarrhythmic potential.

So, is it safe to assume the dig f/by lopressor decreased his rate? Usually digoxin alone does not suppress ectopy such as AFib.

BTW, what did the 12 lead ECG indicate & what about labs such as lytes and cardiac enzymes like Troponin I?

BTW2, even though this patient is asymptomatic I wonder if a visit to the EP lab has been considered?