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The Crashing Atrial Fibrillation Patient « The Central Line

The Crashing Atrial Fibrillation Patient


Your patient is pale and diaphoretic. Blood pressure is 70/50. Heart rate is 178. EKG shows atrial fibrillation… What are you going to do???

Yeah, yeah the Pavlovian ACLS response–You cardiovert. Wonderful, except it didn’t change a thing. Now what?

In this episode, I discuss the crashing atrial fibrillation patient. Essentially when the shock fails, you need to get the BP up to give you some room to work and start your meds.

[Click to read more and hear the podcast]

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  1. #1 by MEL PEARLMAN - March 13th, 2010 at 02:54

    push-dose pressor was a good review of uses for pressors that could be used more often; any thoughts about the effects of phenylephrine on the cerebral circulation in a patient with an ischemic stroke?

  2. #2 by Scott D. Weingart, MD FACEP - March 13th, 2010 at 23:07

    If the problem is vasodilation, phenylephrine’s alpha will improve cerebral blood flow. However, I have found often times the problem is cardiac output and I prefer norepinephrine as my drip pressor and epineprhine as my push-pressor in these patients.

  3. #3 by Ernest L - December 11th, 2011 at 02:58

    I’m a pharmacist practicing in a CCU in Canada and I just heard this podcast and wanted to share a few comments:

    1) In Canada, our most recent guidelines for managing AF/flutter in the ER have recommended against the use of amiodarone (and sotalol) as the evidence shows it’s of very little value for up to 6hrs (which makes sense given amiodarone’s kinetics).

    2) If electrical cardioversion +/- pharmacologic is selected, can’t stress the need for full systemic anticoagulation AND a TEE (if the patient can wait) to rule out clot

    3) In my experience, the patients that are really refractory to cardioversion and even rate-limiting agents are those that have atria that are totally stretched out, and if it’s clinically indicated, a shot of diuretics can go a long way to upping your chances of success.

    4) Procainamide is a fantastic choice, however, it also increases the chance that an impulse will pass through the AV. Thus, conduction must be controlled using an AV blocker before it’s started. Otherwise, with some close monitoring it’s a great substitute for amio.

    Thanks! Btw, for the future how do I comment on the emcrit.org blog?

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