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EMS and Atrial Fibrillation

EMS and Atrial Fibrillation. John H. Burton MD, FACEP Residency Program Director Department of Emergency Medicine Albany Medical Center. burtonj@mail.amc.edu. Albany. NY. I. EMS and AFib 1. Identify the Rhythm 2. RATE assessment 3. RHYTHM plan based on stability.

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EMS and Atrial Fibrillation

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  1. EMS and Atrial Fibrillation John H. Burton MD, FACEP Residency Program Director Department of Emergency Medicine Albany Medical Center

  2. burtonj@mail.amc.edu Albany NY I

  3. EMS and AFib 1. Identify the Rhythm 2. RATE assessment 3. RHYTHM plan based on stability

  4. We’re not going to talk about…

  5. Prehospital Treatment Studies • Few Small Studies • Do No Harm

  6. What is Afib?

  7. Anatomy & Pathophys

  8. It’s Irregularly Irregular…..

  9. Atrial FlutterFlutter…=…Fib

  10. Atrial Flutter Atrial beats usually produced in Right Atrium - Regular Conduction with Sawtooth Ps

  11. Hospitalization for AF in the US 1985-1999 Circulation 2003; 108

  12. Valvular disease CAD – MI HTN CHF Cardiomyopathy Pericarditis Intracardiac masses Cardiac surgery Congenital Conduction system disease Myocarditis REASON – Cardiac

  13. Pulmonary Hypoxia COPD PE Infection Chest Trauma Toxic/Metabolic Alcohol, Drugs Hyperthyroidism Pheochromocytoma Hypo K,Mg Idiopathic REASON – Non-Cardiac

  14. AF REASON:Bottom Line • Everyone deserves an initial work-up • New-Onset -Heart -Lungs -Metabolic -Tox -Endocrine -??? • Chronic Previous work-up

  15. ED AF Work-up • New-Onset -CBC -Lytes -Chest XR -TSH -Tox, if indicated -Enzymes, if indicated • PAF or Chronic -As indicated- CBC,Lytes,Tox,Enzymes

  16. Why do Patients call EMS for A Fib? • Symptoms related to New Onset A Fib • 2. Rate Control symptoms from either New Onset or Chronic A Fib

  17. Symptoms of A Fib • Sensation of palpitations • Pulse may feel rapid, racing, pounding • Pulse may feel regular or irregular • Dizziness, lightheadedness • Fainting • Confusion • Fatigue • Shortness of breath • Sensation of tightness in the chest

  18. Chronic AF

  19. EMS and AFib 1. Identify the Rhythm 2. RATE assessment 3. RHYTHM plan based on stability

  20. Beta Blockers Ca Channel Blockers Digoxin Others? Magnesium Clonidine Amiodarone Adenosine Rate Control Options

  21. Beta-Blockers • Metoprolol 5-10 mg IV boluses • IV Esmolol appears most useful in studies • THE CHOICE in AF secondary to MI, hyperthyroidism, or catecholamine excess

  22. Calcium Channel Blockers • Verapamil vs. Diltiazem • Highest Response rate • Diltiazem associated with less hypotensive episodes

  23. Digoxin • Digitalis used > 200 years • Slow-onset…doesn’t work acutely • + inotropic effects – role in CHF • Stop giving this drug for AF!

  24. Amiodarone • Effective for rate control, conversion and maintenance • Rate control via beta effects • Cost – 150 mg = $14

  25. Rate Control: Bottom Line • Give Diltiazem IV • Unless…ischemia, then give Beta Blockers IV

  26. EMS and AFib 1. Identify the Rhythm 2. RATE assessment 3. RHYTHM plan based on stability

  27. Unstable vs Stable • Unstable pts = less than 1% ED encounters • Indications -“hemodynamic compromise” • severe ischemia • hypotension (SBP<90) • loss of consciousness • heart failure

  28. ED RhythmConversion? • Who? • Unstable patients • Consider for low risk pts with onset < 48 hours • AF in patients already anticoagulated • Why? • Patients want it…symptoms, meds, tolerance • Doctors want it…Cardiology, PCP consults

  29. EMS RhythmConversion? • Who? • Unstable patients • Why? • Unstable patients

  30. 1% or less!!!! Cardiovascular instability solely attributed to AFib is uncommon!

  31. HTN Diabetes Prior TIA or Stroke LV Dysfunction/CHF Rheumatic MV Disease Age >65 Prolonged AF: >48hours Predictors of thromboembolism with cardioversion

  32. Class IA Procainamide Quinidine Class IC Flecainide Propafenone Class III Ibutilide Amiodarone Sotalol Rhythm Conversion Options

  33. EMS: electrical rhythm conversion...

  34. Cardioversion • Sedation: Midazolam, Valium, Etomidate • Pad Location: front/back • Synchronized • Biphasic

  35. 1% or less!!!! Cardiovascular instability solely attributed to AFib is uncommon!

  36. EMS and AFib 1. Identify the Rhythm 2. RATE assessment 3. RHYTHM plan based on stability

  37. In the ED 1. REASONfor AF 2. RATE plan 3. RHYTHM plan 4. RISK of stroke/ anticoagulation

  38. Thank You!burtonj@mail.amc.edu

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