If afib with RVR tell who
Attending must be notified via text page at this point
In acute stroke patients what should you consider
Strongly consider digoxin over amiodarone
What is considered afib with RVR in this algorithm
Irregularly irregular rate and rhythm with ventricular rate >110
While assessing hemodynamics
MgSO4 IV 2 g (?)
If unstable
SBP <90 over 30 minutes or on inotropic agent,ACLS/cardioversion
If marginally stable
SBP 90-120, recent stroke, evidence of perfusion-dependence
What do you do for marginally stable
Continuous infusion for ventricular rate control of ESMOLOL 10 mg bolus and drip at 50 mcg/kg/min
How do you titrate esmolol for this purpose
Titrate in 50 mcg/kg/min increments q 5 minutes to maximum dose of 200 mcg/kg/min
If goal HR is not achieved with esmolol for moderately stable,
Start eitherAmiodarone IV 150 mg bolus +/- drip at 1 mg/min x 72 hours. Repeat bolus as tolerated to achieve rate controlORDigoxin IV 5 mcg/kg load, then 2.5 mcg/kg q 6 hour 2xStrongly consider cardiology consultation
If patient is stable they are
SBP >120, on no inotropic agents, recent stroke or evidence of perfusion-dependence
If stable, do what first
Metoprolol IV 5 mg 1 5 minutes up to 3 doses as tolerated
If metoprolol works, do what next
Start metoprolol IV 5 mg q 6 hours
If metoprolol doesn't work
Continuous infusion for ventricular rate control using:1st line or 2nd line drugs
1st line for continuous infusion for ventricular rate control
Esmolol 10 mg bolus and drip at 50mcg/kg/min. Titrate in 50 mcg/kg/min increments q 5 minutes to maximum dose of 200 mcg/kg/min
2nd line for continuous infusion for ventricular rate control in STABLE patient
If goal HR not achieved, STOP esmolol, start diltiazem IV .25 mg/kg, can repeat once at 5 minutes. Start diltiazem drip at 5-15 mg/hr
If therapy is effective in stable patient with 1st or 2nd line ventricular rate control or marginally stable in pt with amiodaronge or digoxin...
START long-acting therapy at 6 hours
If 1st line and 2nd line treatment for stable doesn't work...
Amiodarone or digoxin-Amiodarone: IV 150 mg bolus +/-drip at 1 mg/min x 72 hours. Repeat bolus as tolerated to achieve rate control-Digoxin IV 5 mcg.kg load, then 2.5 mcg/kg q6hr 2x
If none of this works
Consider pharmacologic or mechanical cardioversion with TEE if no contraindications (sx>48 hours, acute stroke)
Rapid clinical assessment of afib with RVR includes
1. STAT EKG2. Remove offending agents if possible3. Evaluation and initiation oftreatment for reversible inciting factors
Purpose of STAT ekg
Confirms diagnosis, rules out aberrant conduction (Wolf parkinson white) and narrow complex tachycardia
What offending agents possibly removed
1. STOP agents with beta adrenergic properties (norepinepherine, dopamine, etc)2. Convert any pressors to phenylepherine or vasopressin
What reversible inciting factors should be evaluated for
1. Volume status: JVD, Lung crackles, edema, bedside ultrasounds to see if IVC is collapsible and to evaluate global cardiac function2. Oxygenation: ABG3. iNFECTION: CBC, CXR, UA4. Electrolytes: CMP, Mg, phos5: Other: TSH with reflex, urine drug screen6. MI: EKG, troponin q8hr 2x7. Formal TTE or TEE within 24 hours