1) Afib RVR is often triggered by the same etiologies as sinus tachycardia. Before treating the arrhythmia, treat the most likely etiology.
2) In a person with normal cardiac function and structure, afib RVR is not the cause of the patients shock. Patients that are particularly sensitive to afib RVR include those with cardiomyopathies, recent MIs, severe diastolic dysfunction, HOCM, WPW, severe valvular disease, and severe coronary artery disease. In these populations, afib RVR often manifest as hypotension, pulmonary congestion, and possibly ischemia.
3) Procainamide should be the first line treatment in stable WPW with afib. AV nodal blocking agents should be avoided.
4) Review of recent literature suggest:
- Diltiazem is more effective at controlling rate within 30 minutes when compared to metoprolol (Fromm 2015).
- Beta blockers may have a mortality benefit when used in afib RVR & sepsis (Walkey 2016).
- Use of a rate of rhythm controlling agent in ED patients presenting with an acute underlying illness results in an increase in adverse events compared to patients who did not receive rate or rhythm controlling agents (Scheuremeyer 2015).
5) Physicians should make an effort to optimize care and improve blood pressures before choosing a rate/rhythm controlling agent. Physicians should consider the patient's clinical status and comorbidities when selecting a treatment option.
1. The first key in assessing a patients with dizziness is to define the problem: dizziness is not a medical term, and vertigo is not a diagnosis.
2. If a patient has nystagmus, it is important to interpret and document the nystagmus in a clinically meaningful way which will support your diagnostic decision making.
3. To adequately test the cerebellum, all three of the following must be assessed: limb ataxia, truncal ataxia, and oculomotor control.
4. Correct patient selection is essential when performing the Dix-Hallpike maneuver or the Head Thrust Test. The only patients who are appropriate candidates for the Dix-Hallpike test are those with a history consistent with BPPV. Similarly, the only patients who are appropriate candidates for the head thrust test (and the HINTS exam) are those with acute vestibular syndrome.
5. If the patient has the constellation of signs and symptoms that comprise acute vestibular syndrome, perform the HINTS exam to attempt to distinguish central from peripheral causes
6. Recognize that brain CT rarely identifies early-stage cerebellar infarction. DWMRI is reasonably sensitive for detecting cerebellar infarction early, but it is less sensitive than appropriately performed oculomotor assessment.