AFib RVR

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//Buzzzzzzzzz// It's the pager hanging on your scrub pants. //'Rapid Response Team to Room 3115'//, it reads. Not too far away from the Residents' Lounge. //'Oh thank goodness! It's $name,'// says the patient's nurse. You are the first physician to arrive. The RN states that she just received a call from PMD (telemetry) with concerns about atrial fibrillation with rapid ventricular rate around 150 bpm. She adds that the patient just started complaining of palpitations. Laying in bed is a mid-70s-appearing gentleman with many RNs at bedside. You decide to... [[Obtain a focused history|Focused History]] [[Conduct a focused physical exam|Focused Exam]] [[Obtain a 12-lead EKG|EKG]] [[Review the patient's chart|Chart Review]] Click on an option to continue.

//'Hello Mr. Isaac. My name is <<print $name>>, one of the residents here. How are you feeling right now? I heard you're experiencing some symptoms.'// He explains that he was simply resting in bed when he started to feel a fluttering sensation in his chest a few minutes ago. Then suddenly he noticed his nurse rush into the room looking concerned and before he knew it a whole team of people arrived. //'Things have felt off all day, doctor,'// he says. He localises the sensation to the sternal region. No active chest pain or dyspnea. He adds that he also feels very lightheaded, as if he is about to pass out. No diaphoresis or nausea. //'I've had the shakes all day too,'// he adds. You're not sure what he means. //'Seems like your heart rate is suddenly high, Eugene. Has this ever happened before?,'// you ask trying to redirect the conversation. //'I think so. My cardiologist says I have to take medications to keep my heart rate controlled.'// //'So this isn't new for you? Have you been told that you have atrial fibrillation?'// //'Yes, that's it. That sounds familiar.'// //'Do you take any blood thinners?'// //'I think so. I can't really remember my medications right now. I take so many.'// After obtaining a brief history you decide to... [[Conduct a focused physical exam|Focused Exam]] [[Obtain a 12-lead EKG|EKG]] [[Review the patient's chart|Chart Review]] [[Order medications through the EMR|Medication administration]] [[Attach the patient to an automated external defibrillator|AED]]

You decide to perform a focused physical exam on Mr Isaac. <ul> <li>He appears to be comfortably laying supine in bed. No apparent distress. Diaphoretic.</li> <li>His heart rate is tachycardic with an irregularly irregular rhythm. No apparent murmurs or gallop beats however he is too tachycardic for you to be sure. No apparent jugular venous distention, however the bed is upright at 60 degrees.</li> <li>His respirations are non-laboured. On auscultation, you notice mild bibasilar inspiratory crackles. His lungs seem clear otherwise.</li> <li>A brief exam of his legs does not reveal any pitting edema. Periphal skin is dry to touch.</li> </ul> <ul> <li>A manual blood pressure cuff reveals a BP of 100/40.</li> <li>Heart rate by palpation is estimated to be around 140 bpm.</li> <li>Pulse oximetry is 94% on room air.</li> <li>Respirations at 19 rpm.</li> </ul> From here you decide to... [[Obtain a focused history|Focused History]] [[Obtain a 12-lead EKG|EKG]] [[Review the patient's chart|Chart Review]] [[Order medications through the EMR|Medication administration]] [[Attach the patient to an automated external defibrillator|AED]]

An EKG is obtained: <img src="https://nl.ecgpedia.org/images/f/f8/Afib_f_VR_ecg.jpg" alt="12 Lead EKG w/ AFib RVR" width='800'> <<textbox "$EKG_interpretation" "Enter your interpretation" "EKG_Read">> Press enter to continue.

You log into the EMR and open the patient's chart. The last progress note from the medical team simply has an automated assessment list and does not elaborate on the management plan. As such, the admission note catches your eye. Reading through, you note down some pertinent points: Mr Eugene T. Isaac is a 73 year-old gentleman with a past medical history of coronary artery disease (with a history of many percutaneous coronary interventions), paroxysmal atrial fibrillation (without systemic anticoagulation due to his history of bleeding), heart failure with preserved ejection fraction, hypertension, type 2 diabetes mellitus (with an A1c of 13% from 2 months ago), hyperlipidemia, BPH, and gout. He was admitted 2 days ago for a suspected UTI and was started on intravenous ceftriaxone. //Ugh, these notes barely have any info.// Navigating through the other sections of the chart, you note: <ul> <li>His home medications include losartan, metoprolol, aspirin, clopidogrel, atorvastatin, metformin, glipizide, insulin glargine and lispro, furosemide, tamsulosin, and allopurinol. All of which were continued on admission.</li> <li>He has also been hypokalemic, with a potassium of 2.9 mEq/L (2.9 mmol/L) on admission. It has not been re-checked.</li> <li>Urine and blood cultures returned positive earlier today for non-lactose fermenting gram-negative bacilli.</li> <li>He is being managed with intravenous ceftriaxone only.</li> <li>Documented as having an ejection fraction of 40% on his last echocardiogram from 2 years ago.</li> </ul> You also note that he has been recurrently febrile, with a max temperature of 38.8 degrees centigrade (102 degrees fahrenheit) over the last 24 hours. Because you are a talented young internist, you also notice that his blood pressure has been on the downward trend with mild widening of his pulse pressure, most recently charted as 115/45. His heart rate has been in the 70s-90s since admission. Otherwise his recent charted vitals have been unremarkable. After obtaining this information, you decide to... [[Obtain a focused history|Focused History]] [[Conduct a focused physical exam|Focused Exam]] [[Obtain a 12-lead EKG|EKG]] [[Order medications through the EMR|Medication administration]] [[Attach the patient to an automated external defibrillator|AED]]

You log into the EMR and open the medication order entry page. There are a few medications you are considering... Click on an option to continue. <<if not hasVisited("Metoprolol")>>[[IV metoprolol, 5 mg|Metoprolol]]<</if>> <<if hasVisited("Metoprolol")>>[[IV metoprolol, 5 mg|Metoprolol 2]]<</if>> [[IV diltiazem, 10 mg|Diltiazem]] [[IV 0.9% saline, 1 litre, at 999 mL/hr|IV crystalloid]] [[IV lactated ringers, 1 litre, at 999 mL/hr|IV crystalloid]] [[You have second thoughts about giving a medication, and attach the patient to an automated external defibrillator|AED]] <hr> <<if not hasVisited("Focused Exam")>>[[Conduct a focused physical exam|Focused Exam]]<</if>> <<if not hasVisited("Focused History")>>[[Obtain a focused history|Focused History]]<</if>> <<if not hasVisited("EKG")>>[[Obtain a 12 Lead EKG|EKG]]<</if>> <<if not hasVisited("Chart Review")>>[[Review the patient's chart|Chart Review]]<</if>>

You instruct the RN to bring in the AED/cardiac monitor and attach it to the patient. //'Woah, what's that? What's going on doc?'// //'Just attaching you to the cardiac monitor, sir.'// After the pads are attached, the AED is turned on and the monitor shows an irregularly irregular rhythm at approximately 150 bpm. Considering the clinical scenario, you decide to... [[Perform unsynchronised cardioversion with 200 J|Defibrillation]] [[Perform synchronised cardioversion with 100 J|Cardioversion]] [[You have second thoughts about electrical cardioversion and consider medications|Medication administration]] <hr> <<if not hasVisited("Focused Exam")>>[[Conduct a focused physical exam|Focused Exam]]<</if>> <<if not hasVisited("Focused History")>>[[Obtain a focused history|Focused History]]<</if>> <<if not hasVisited("EKG")>>[[Obtain a 12 Lead EKG|EKG]]<</if>> <<if not hasVisited("Chart Review")>>[[Review the patient's chart|Chart Review]]<</if>>

<img src="https://nl.ecgpedia.org/images/f/f8/Afib_f_VR_ecg.jpg" alt="12 Lead EKG w/ AFib RVR" width='800'> This 12-lead EKG reveals atrial fibrillation with a rapid ventricular rate. There are no apparent ST-T changes or T-wave inversions. Upon review of the EKG, you decide to... [[Obtain a focused history|Focused History]] [[Conduct a focused physical exam|Focused Exam]] [[Review the patient's chart|Chart Review]] [[Order medications through the EMR|Medication administration]] [[Attach the patient to an automated external defibrillator|AED]] <br> //EKG courtesy of ECGpedia.org. Obtained from https://en.ecgpedia.org/index.php?title=File:Afib_f_VR_ecg.jpg.

The RRT nurse draws up 5 mg of metoprolol from a vial and it's administered to the patient. //'I'm gonna go grab more,'// she says, motioning to the empty vial of //Mellowpressor// in her hand. You nod in acknowledgement. After a few minutes, you re-evaluate Mr Isaac. His heart's rhythm is still irregular and rapid at 130 bpm. A manual blood pressure reading is 90/35. //'Damn, I was hoping that would work,'// says Mr Isaac's nurse. //'That what wou--,'// //'Your heart rate is still high, Eugene. That medication didn't work,'// he clarifies while giving you a glare. Pressured to do something, you decide to... [[Order another dose of IV metoprolol, 5 mg|Metoprolol 2]] [[Try IV diltiazem, 10 mg|Diltiazem 2]] [[Order 0.9% saline, 1 litre|IV crystalloid]] [[Attach the patient to an AED|AED]]

The RRT nurse returns from the medication room with a vial labelled //Heartizem// and administers 10 mg of intravenous diltiazem to Mr Isaac. After a few minutes, a repeat physical exam reveals an irregularly irregular heart rate at around 80 bpm. Blood pressure is 92/40. You feel comfortable with this intervention and leave instructions to the nurse to start intravenous 0.9% saline at 100 mL/hr and re-check vitals after a few hours. -----3 hours later----- //Thirty minutes left.// It's been a long call shift, but a well deserved trip home is on the horizon. You start to prepare your patient signouts when those dreaded chimes are heard overhead. //CODE BLUE in Room 3115. CODE BLUE in Room 3115.// It's Mr Isaac. You rush to 3115 and are met by his nurse. //'I have no idea what happened! My nursing student came to check vitals and she called me in right away. He was breathing really hard. His lips were blue. I called for help then suddenly he was unresponsive and coded.'// High-quality CPR is started and after 6 minutes spontaneous circulation is re-established. Mr Isaac is then triaged to the medical ICU for further care. [[The End. Click here to continue.|Conclusion]]

//Click-click-click...// The room is quiet enough to hear the stiff resistance of the AED's dials as Mr Isaac's nurse sets the device to 200 joules. Mr Isaac is given 2 mg of IV midazolam. His eyes gently close as yours sharply turn to the AED. //'CHARGING!'// declares the nurse, as you and the rest of the team reflexively step away from the patient's bed. //'Clear!'// The nurse's thumb stamps down on the glowing shock button and you notice Mr Isaac jerk in bed. His face grimaces then suddenly his neck goes limp. //Wait, did you syncronise?!// asks the RRT nurse concerningly. //'He's in ventricular tachycardia! I got no pulse!'// CODE BLUE is called overhead as you stare at the wide-complex rhythm on the cardiac monitor. It feels like an eternity passes as the crash cart is wheeled into the room. After 4 minutes of high-quality CPR and ACLS, ROSC is achieved and Mr Isaac is triaged to the critical care unit. [[The End. Click here to continue.|Conclusion]]

//Click-click-click...// The room is quiet enough to hear the stiff resistance of the AED's dials as Mr Isaac's nurse sets the device to 100 joules. Mr Isaac is given 2 mg of IV midazolam. His eyes gently close as yours sharply turn to the AED. //'CHARGING!'// declares the nurse, as you and the rest of the team reflexively step away from the patient's bed. //'Wait, make sure to sync it!'// you say. The rapid response nurse promptly confirms. //Whew.// The nurse's thumb stamps down on the glowing shock button and you notice Mr Isaac jerk in bed. His face grimaces as he groans out in discomfort. The cardiac monitor is showing a sinus rhythm at 78 bpm. [[The End. Click here to continue.|Conclusion]]

One litre of intravenous crystalloid is given to Mr Isaac and he is re-evaluated thereafter. //'Thanks, $name. I feel a bit better now,'// says Mr Isaac. //'Glad to hear!'// you reply as you repeat a focused exam. His BP is now 120/50 with a heart rate of 90. He is still in an irregularly irregular rhythm. Because you are a talented young internist and are concerned about sepsis, you order more intravenous fluids to ensure that Mr Isaac receives 30 mL per kg. After a full fluid resuscitation, Mr Isaac tells you that he feels much better and is no longer experiencing palpitations. A repeat 12-lead EKG reveals atrial fibrillation with controlled heart rate at approximately 85 bpm. You place an order for continuous intravenous crystalloid, discontinue furosemide, change ceftriaxone to cefepime, and advise Mr Isaac's nurse to notify the Rapid Response Team with any other concerns. [[The End. Click here to continue.|Conclusion]]

//'Have a good call.'// It sucks seeing your colleagues leave for home when you still got hours left on your call shift. //'See ya,'// you respond. //There goes backup. Whew. Just a few hours left.// The countdown is on. <<textbox "$name" "Enter your name to begin." "AFib RVR">> Press enter to continue.

The RRT nurse returns from the medication room with a vial labelled //Heartizem// and administers 10 mg of intravenous diltiazem to Mr Isaac. //'I don't feel too g--,'// says Mr Isaac softly a few moments after receiving the medication. You turn and notice his eyes roll backwards. //'Eugene? Eugene, can you hear me?'// asks the RRT nurse as she palpates for a central pulses. //'Nothing. Get the crash cart, call the code.'// CODE BLUE is called overhead. After 4 minutes of high-quality CPR and ACLS, ROSC is achieved and Mr Isaac is triaged to the critical care unit. [[The End. Click here to continue.|Conclusion]]

The patient's nurse removes a vial of //Mellowpressor// from her computer-cart's storage drawer and administers 5 mg to the patient. //Wait, I thought the RRT nurse went to get more...// //'I don't feel too g--,'// says Mr Isaac softly. You turn and notice his eyes roll backwards. Just then, the RRT nurse returns and sees the patient unresponsive. //'Eugene? Eugene, can you hear me?'// she asks as she palpates for a central pulses. //'Nothing. Get the crash cart, call the code.'// CODE BLUE is called overhead. After 4 minutes of high-quality CPR and ACLS, ROSC is achieved and Mr Isaac is triaged to the critical care unit. [[The End. Click here to continue.|Conclusion]]

Hey, $name! Thanks for completing this practice scenario. I hope you found it fun and helpful. Our goal with these scenarios is to help improve decision making and confidence for common rapid response calls we experience. This case was also written as a narrative piece to explore the emotions and humanity that often emerge in healthcare. As busy physicians we often miss the stories, personalities, and experiences of each of our patients. I hope this scenario encourages you to pause and appreciate these whenever you can. Here are a few teaching and discussion points: <ul> <li>Breakthrough arrhythmias, especially supraventricular arrhythmias, often arise in response to a trigger or physiologic stress. It is important to keep this in mind when we respond to these type of calls. In this case, the patient was showing signs of worsening sepsis. Other common triggers to consider are acute coronary syndrome, acute heart failure, dehydration, and electrolyte derangements. While treating the arrhythmia is important, addressing the underlying trigger as best as feasible is recommended.</li> <li>While non-dihydropyridine calcium channel blockers like diltiazem are effective rate-controlling agents for supraventricular tachyarrhythmias, they are also potent negative inotropes. We have to keep this in mind for patients with reduced ejection fraction or for patients who are exhibiting signs and symptoms of acute heart failure.</li> <li>Electrical cardioversion is an effective, guideline-based option for unstable arrhythmias--just make sure you hit synchronise when it's appropriate! ACLS guidelines are a reliable tool to use if you are unsure of how to approach acute arrhythmias.</li> </ul> --//Written and edited by Amreet Sidhu, MD.// --//Reviewed by Kat Zechar, MD.// //References:// <ol> <li>Koster, R. W. EKG image for atrial fibrillation with RVR. //Atrial Fibrillation//, ECGPedia.org, 10 August, 2010, https://en.ecgpedia.org/index.php?title=File:Afib_f_VR_ecg.jpg. </li></ol>