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Management of Atrial Fibrillation in the Acutely Ill

7/27/2017

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Picture
  • In the acutely ill patient with rapid Afib, management should focus on quick rate control
  • IV diltiazem should be the treatment of choice
  • Bolus is crucial; re-bolus is crucial – they brake the vicious cycle of fast ventricular rate, reduced LV filling, reduced stroke volume, all resulting in further adrenergic activation
  • Diltiazem drip does not reduce the heart rate; it maintains whatever you achieved with the bolus
  • Never order “diltiazem drip, titrate to heart rate”
  • Ideal dose of initial diltiazem bolus is 0.25 mg/kg over 2 minutes
  • Ideal dose of re-bolus is 0.35 mg/kg over 2 minutes
  • Marked hypotension may limit giving the optimum doses of diltiazem boluses
  • Under these circumstances, there are several options for pre-treatment before the IV diltiazem bolus
    • IV fluid boluses
    • IV digoxin, 0.5 mg
    • Phenylephrine, 100-300 mcg IV push over 10-30 sec
  • With the help of one or more of the above, IV diltiazem can almost always be given safely
  • Consider IV beta blocker (esmolol) instead of diltiazem for patients with rapid Afib and acute MI, ongoing ischemia, thyrotoxicosis and HOCM crisis
  • IV amiodarone is almost never needed for rate control
  • If rate control is still inadequate despite maximum tolerated doses of diltiazem, adding 0.5 mg of IV digoxin will frequently “finish the job”
  • For critically ill patients with rapid Afib, consider emergent cardioversion
  • Do not shock the patient with MAT or with repetitive Afib characterized by the presence of occasional sinus complexes
  • These patients are frequently good candidates for rhythm management with amiodarone or beta blocker
 


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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction