Key Feature 3a: In an individual presenting with chronic or paroxysmal atrial fibrillation: Explore the need for anticoagulation based on the risk of stroke with the patient. Skill: Patient Centered, Clinical Reasoning Phase: Diagnosis, Treatment Key Feature 3b: In an individual presenting with chronic or paroxysmal atrial fibrillation: Periodically reassess the need for anticoagulation. Skill: Clinical Reasoning Phase: Hypothesis generation, Follow-up Key Feature 4: In patients with atrial fibrillation, when the decision has been made to use anticoagulation, institute the appropriate therapy and patient education, with a comprehensive follow-up plan. Skill: Clinical Reasoning Phase: Treatment, Follow-up Key Feature 5: In a stable patient with atrial fibrillation, identify the need for rate control. Skill: Clinical Reasoning Phase: Hypothesis generation, Treatment Key Feature 6: In a stable patient with atrial fibrillation, arrange for rhythm correction when appropriate. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Treatment In a patient with atrial fibrillation, whether or not they should be anticoagulated is based on the risk for stroke versus having a serious bleed. The CHADS2-VASc risk stratification score is the standard assessment tool to assess for the risk of stroke, while the HAS-BLED risk stratifications score is the equivalent to asses for the risk of a major bleed. In realtime, I use a medical calculator app (Canadian Cardiovascular Society) to determine the risk scores for the patient in front of me to help me make a decision. It's important to have a patient-centered conversation. Although the chances of having a major bleed may be higher for the patient than the risk of stroke based on their risk stratification scores, the majority of such patients may prefer to be anticoagulated given the proportional risk for decrease in quality of life should one versus the other occur. It is important to periodically reassess the need for anticoagulation as a patient's risk of stroke, risk of sustaining a major bleed, and goals of care may change over time. The Canadian Cardiovascular Society Atrial Fibrillation Guideline recommends the following for prevention of stroke and systemic embolism:
In follow-up care of a patient who has been diagnosed with atrial fibrillation, be it paroxysmal, persistent, or permanent, the following issues should be reviewed:
The Canadian Cardiovascular Society Atrial Fibrillation Guideline recommends the following for rate control of Atrial Fibrillation:
The Canadian Cardiovascular Society Atrial Fibrillation Guideline recommends the following for rate control of Atrial Fibrillation:
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Key Feature 1: In a patient who presents with new onset atrial fibrillation, look for an underlying cause (ex: ischemic heart disease, acute myocardial infarction, congestive heart failure, cardiomyopathy, pulmonary embolus, hyperthyroidism, alcohol, etc.).
Skill: Clinical Reasoning Phase: Hypothesis generation In a patient who presents with new onset atrial fibrillation, either picked up because they are symptomatic (ex: palpitations, decreased exercise tolerance, dyspnea), as an incidental finding on physical examination (ex: irregularly irregular pulse), or on an ECG done for another reason (ex: presurgical baseline), it is important to look for an underlying cause. This is important so as to treat any underlying disease that has its own cluster of negative consequences, but also to identify any possible reversible reason for having atrial fibrillation. Atrial fibrillation increases the risk of stroke and peripheral embolisation, can decrease quality of life, and may increase the risk of death. Although these risks can be mitigated with medications, medications do not eliminate them altogether. Potential causes of reversible atrial fibrillation to assess for include:
Important associated disease processes to look for include:
Advanced Cardiac Life Support Key Feature 1: Keep up to date with advanced cardiac life support (ACLS) recommendations (i.e., maintain your knowledge base). Skill: Professionalism Phase: Treatment Key Feature 2: Promptly defibrillate a patient with ventricular fibrillation (V fib), or pulseless or symptomatic ventricular tachycardia (V tach). Skill: Clinical Reasoning, Selectivity Phase: Treatment Key Feature 3: Diagnose serious arrhythmias (V tach, V fib, supraventricular tachycardia, atrial fibrillation, or second- or third-degree heart block), and treat according to ACLS protocols. Skill: Clinical Reasoning Phase: Diagnosis, Treatment Atrial Fibrillation Key Feature 2a: In a patient presenting with atrial fibrillation: Look for hemodynamic instability. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation Key Feature 2b: In a patient presenting with atrial fibrillation: Intervene rapidly and appropriately to stabilize the patient. Skill: Clinical Reasoning, Selectivity Phase: Treatment I am currently certified as an ACLS Provider. Expiring in April 2019, I will need to retake the course at some point in time prior to this expiry date so I can keep up to date and have some welcome practice. If I encounter a patient who is unresponsive, I need to assess for a pulse straight away. If no pulse is definitively felt within the first 10 seconds (while simultaneously assessing for breathing), I need to activate the emergency response system. In the hospital this would be to call a "Code Blue." Once activated, I need to start CPR straight away. My priority is to perform high quality CPR until a defibrillator arrives and the cardiac rhythm is determined to be one of the following:
An automated external defibrillator would sense whether or not the rhythm is VF or VT automatically and simply directs the user to shock or not, while a manual defibrillator would require me to be able to read the rhythm strip and decide whether is represents VF or VT (shockable rhythms) or not (everything else being nonshockable). If a shockable rhythm is present, shocking that rhythm is the MOST IMPORTANT INTERVENTION I can do to save someone's life, so as soon as there is a defibrillator present, it is critical to have it set up ASAP and deliver a shock if the patient is in VF or VT. Other life-saving interventions include providing high-quality CPR, and using epinephrine (1 mg IV q3-5min) +/- adenosine (up to 2 times, first IV bolus of 300mg, second of 150 mg). There may also be the circumstance in which I encounter a patient with a slow heart rate (bradyarrhythmia, <50 bpm) or a rapid heart rate (tachycardia, >100 bpm, usually >150 bpm to cause serious symptoms or signs), and I must determine if their heart rate is life-threatening and in need of electrical intervention. Let's start with the patient who has a bradyarrhythmia. Bradyarrhythmia For an unwell patient with a bradyarrhythmia, my first step is to consider the ABCs: Airway, Breathing (supplemental oxygen if hypoxemic), Circulation (cardiac monitoring to identify rhythm, monitors for BP and oximetry, obtain IV access, and get a 12-lead ECG). Urgent intervention is warranted if the patient has any of the following serious features (even if the 12-lead ECG has not yet been obtained so as to accurately characterise the rhythm):
If I need to perform transcutaneous pacing, here are the steps to so so:
If the patient is only mildly symptomatic from poor perfusion secondary to the bradyarrhythmia, it is still important to address the arrhythmia, but there is a bit more time. The ECG can be examined and we can look for a correctable etiology for the bradyarrhythmia. Types of bradyarrhythmias (from the ACLS Provider Manual). Generally speaking, the more progressive the block, from sinus to complete AV block, the more clinically significant the ramifications. Also note that sinus bradycardia may in fact be physiologic (Muhammad Ali reportedly had a heart rate in the 30s because he was so in shape - quite the anomaly!) Tachyarrhythmia
For an unwell patient with a tachyarrhythmia, like with a bradyarrhythmia (or anytime a patient appears unwell), my first step is to consider the ABCs: Airway, Breathing (supplemental oxygen if hypoxemic), Circulation (cardiac monitoring to identify rhythm, monitors for BP and oximetry, obtain IV access, and get a 12-lead ECG). Urgent intervention is warranted if the patient has any of the following serious features (even if the 12-lead ECG has not yet been obtained so as to accurately characterise the rhythm), and these are the same as the serious features to look for with a bradyarrhythmia
Steps to perform synchronised cardioversion:
If the patient is only mildly symptomatic from poor perfusion secondary to the tachyarrhythmia, like with bradyarrhythmias, it is still important to address the arrhythmia, but there is a bit more time. The ECG can be examined and we can look to see whether or not the QRS complexes are wide (≥0.12 sec). For the wide-complex tachyarrhythmia: If it is monomorphic, consult an expert. If it is polymorphic, treat with immediate unsynchronised cardioversion (notice the description is the same as for VF, which requires defibrillation in a patient without a pulse - the only difference here is that unsynchronised cardioversion sends less energy with each shock than a defibrillation dose) and consult an expert. For the narrow-complex tachyarrhythmia:
So, that is my ultrabasic and never-done-in-real-life approach to managing bradyarrhythmias and tachyarrhythmias. By having this approach, hopefully if I see one being treated I can figure out what's up. SUMMARY: If a patient is found to have bradycardia (<50) or tachycardia (>150) and is also having symptoms of decreased perfusion, heed the ABCs. If they have any of the following signs or symptoms:
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