Curbside consult with electrophysiologist Randy Jones MD about the fine points of atrial fibrillation managment.
Atrial fibrillation management…including
- Proper pad placement.
- The difference between a-fib and a-flutter.
- How much energy to use.
- What to do when that nice sinus rhythm after cardioversion turns back into a-fib.
- What’s the deal with mixing calcium channel and beta blockers?
- The best agents for acute rate control.
- Do we need to worry about ventricular dysrhythmias after cardioversion?
- IV Procainamide for emergency department cardioversion of a-fib
About Rob Orman
Hey Rob,
this podcast You asked for feedback, and now you´ll get some. I am a German medical 5th yera actually working in something like an ED, even though EM in Germany ist so for not a speciality for its own, unfortunately. By chance I found the stuff You and the guys of LITFL, EMRAP and the rest do, and I am very impressed how You use the Web 2.0 media. I definitely think that this way of peer review, the close connections of You guys to each other will improve knowledge in EM by far more than only using the tradiitional approach like writing papers an that stuff. Thanx for doing that for free. I tried to start a podcast with EM-related themes in German, unfortunaly the response is poor, partly probably because currently there is a difficult way to go for EM to become a speciality here, because of huge resistence of the big bosses in IM, Surgery and Anaesthesiology, hope that´ll end up soon.
Please go on guys, You´re doing a great job.
Lars
Love the podcast! Thanks for taking the time to put these out, and please keep them coming.
Very helpful podcast, Rob. Thanks!
You mention that you have to wait 6 hours for an empty stomach prior to procedural sedation. I could be wrong, but my impression has been that has been shown to be unnecessary. Perhaps this would be a useful topic for discussion/debate.
Any chance you will do a podcast on end tidal CO2? Both for procedural sedation, and for it’s many other uses? I’ve tried to use it in my ED for codes, sedation, etc and am stymied by the RN staff every time. We have the equipment, but none of the staff seem to be familiar with how to use it. I believe it’s an invaluable adjunct that we are missing out on.
Cheers,
Joe H.
Portland, Oregon
thanks. in fact in my area in ER.. our cardiologist really are scared of Electrical cardioversion of AF and they prefer to admit all AF patient for amiodarone infusion.. i gave them punch of articles on safety of elect. cardioversion in er.. but still they refuse to do it . part of it due to unfamiliarity with procedural sedation in er..
is there any difference in risk of stroke between pharmacological & electrical cardioversion of acute af in er?
Hassan-
The risk of stroke with cardioversion of properly selected A fib patients is extremely small. The limited data available show no difference in stroke rate between pharmacologic and electrical cardioversion. The stroke rate for both being essentially zero.
@Rob -- I think the key words in your reply to Hassan are “properly selected”. How in the ED setting would you define a “properly selected” patient with AFib (who should therefore be at essentially zero risk of stroke from cardioversion)? I would imagine one key factor in determining lower risk would be very recent onset -- with onset of the arrhythmia not always being easy to determine.
Truly excellent 2-part ERCast podcast. EP cardiologists are the true “arrhythmologists” -- so THANK YOU!
I have 3 comments on this AFib 2-parter with Randy Jones:
1) In my experience -- the need for emergent cardioversion of AFib is rare. The one exception to this might be with very rapid AFib in a patient with WPW (when ventricular rates may attain 250/minute or more). Emergent cardioversion is not benign -- including potential risk for stroke (especially if anticoagulation status is uncertain as it often is). Given that approximately 50% of patients who present with a new AFib episode will be in sinus rhythm within ~24 hours without any specific treatment beyond rate control (with even more spontaneously converting if you fix the precipitating factor -- ie, heart failure) -- I would think the true need for the ED physician to emergently cardiovert AFib (assuming no WPW) would be rare. Listening to your podcast gave me the opposite impression …
2) I was not aware of increased current use of IV procainamide loading for acute conversion of new-onset rapid AFib or AFlutter as was mentioned. Reminds me of the days of Quinidine (similar effect in many ways to procainamide as a IA agent). It didn’t sound like routine use of an AV nodal blocking agent was advocated in your podcast. Because of the real risk (esp. with flutter) of slowing the flutter rate (say from 300-to-200/minute) with unopposed IA effect potentially then leading to 1-to-1 AV conduction (allowing increase of the ventricular rate to ~200/minute) -- shouldn’t an AV nodal blocking agent be routinely given if IV procainamide loading is used for acute AFib-Flutter conversion?
3) As to your comments about combined AV nodal blocking effect using beta-blockers and diltiazem -- my impression had always been that the “no-no” to avoid was giving IV beta-blocker very soon after IV calcium blocker (or vice versa) -- but that IF the patient was already on a PO beta-blocker -- that IV diltiazem was then perfectly safe to use.
THANKS again for a truly excellent 2-part podcast on AFib!
nice review.. although i’m interested in electrical cardioversion of acute AF for those who are low risk, young patients.. i didn’t hear any comment about this practice although it’s much safer than pharmacological cardioversion.
Hassan-
We mainly use electrical cardioversion for recent onset a fib, both in young and old. I offer Procainamide in certain situations such as -- the patient has just eaten, there is anxiety about getting shocked and the patient would prefer meds first…
in fact excellent review and practical… lets suppose I receive a patient who is 60 year old male known AF, EF 30% on warfarin. comes with rapid AF (140/m) . if he is in Heart Failure , am I going to Electrically cardiovert him? since he is already on punch of AVN blockers including digoxin, carvidolol !! keeping in mind that rapid heart rate could be due to underlying stress like heart failure for example. If the shock failed to convert the rythm, will it control the rate? in this case the choice of Rx is very limited. and I’m not aware of the risk of stroke for those who are already on warfarin even if there is thrombus in left atriam ?