Cardiology-A-Fib question

[Paramedic22]

Hello All! Quick question.... I have been a paramedic for 4 years in a very busy municiple system. Today I had a call, and a brain cramp at the same time. I still haven't been able to shake the brain cramp. Here's the call: 50 yo male ANO X3, c/o sudden onset dizziness and a 'chest fluttering' (palpitations) feeling in his chest. He also had slight chest pain, 3 out of 10. HR 100-130 (obvious A-fib on the monitor) B/P 118/70 RR 18 Skin=W+D. 12 lead showed nothing of interest (except for the obvious A-Fib again). Pt has a history of A-Fib. Now, patients who possibly are in A-Fib all the time are prone to throw clots if you break it correct? So, would I be right in believing that treating the A-Fib with cardizem and thinking a Sinus rhythm would be more efficient and relieve the C.P.? Pt doesn't know if he is always in A-Fib, and doesn't know what his meds are. Or, should I treat the C.P., and leave the A-Fib alone....? I don't want him to start drooling half way to the hospital because I induced a stroke.
Fortunately, it worked out... I treated the C.P., because I made up in my mind the A-Fib was his normal perfusing rhythm, and got him to the hospital.... But now I am second guessing myself.

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[MacGyver]

Hello All! Quick question.... I have been a paramedic for 4 years in a very busy municiple system. Today I had a call, and a brain cramp at the same time. I still haven't been able to shake the brain cramp. Here's the call: 50 yo male ANO X3, c/o sudden onset dizziness and a 'chest fluttering' (palpitations) feeling in his chest. He also had slight chest pain, 3 out of 10. HR 100-130 (obvious A-fib on the monitor) B/P 118/70 RR 18 Skin=W+D. 12 lead showed nothing of interest (except for the obvious A-Fib again). Pt has a history of A-Fib. Now, patients who possibly are in A-Fib all the time are prone to throw clots if you break it correct? So, would I be right in believing that treating the A-Fib with cardizem and thinking a Sinus rhythm would be more efficient and relieve the C.P.? Pt doesn't know if he is always in A-Fib, and doesn't know what his meds are. Or, should I treat the C.P., and leave the A-Fib alone....? I don't want him to start drooling half way to the hospital because I induced a stroke.
Fortunately, it worked out... I treated the C.P., because I made up in my mind the A-Fib was his normal perfusing rhythm, and got him to the hospital.... But now I am second guessing myself.

Uhh you should have a protocol in place to handle that situation. If there is no protocol in place, you should have contacted your medical director and asked him.

 

[MedicFL]

I hate when medics say "what does the protocol say" you should be able to think on your own, and use the protocol as a guide. I agree with your treatment, A little ASA and NTG never hurt anyone. His rate wasn't that high and his pressure was good. No reason to go and give him cardizem. If he was that unstable you could have cardioverted him. My system has pulled Cardizem out because of the negative side effects and our relative short transport times...

 

[Paramedic22]

follow the protocol? that's not the best answer MacGyver couldv'e come up with. If you don't want cook-book medicine, a basic, medic, NP, PA, or MD must think things through. Thanks MedicFL!

 

[deleted6669]

a few things...you probably know this but as a review.....
if it's new onset a-fib within 24-48 hrs the goal(not necessarily in the field) will be return to sinus rhythm.
if the pt is unstable( hypotension, chest pain, aloc, etc) the correct tx would be synchronized cardioversion.
there is obviously a risk for throwing clots. some systems would recommend initial aspirin while others would want you to wait so heparin and coumadin could be started in the e.d. if the pt is not coverted. some of this will be protocol driven and some(cardioversion of unstable pt) will be allowable for all medics.
hard to go wrong with treating the primary sx of chest pain here as it is what's new and the reason they called 911 so I don't think anyone would fault you for ntg, asa, o2, and morphine as vitals and clinical situation allowed.
good job by the way.

 

[Paramedic22]

Thanks Emedpa!

 

[viostorm]

I agree with emdpa.

People in AF have myocardial infarctions too, so for this patient with HR 100-130 it is perfectly appropriate to follow your CP protocol. Actually CAD/MI is a common cause of AF.

If HR > 150 and patient has CP, it could be the rate is causing the chest pain. At that point, if you have a special AF protocol (we did when I worked in richmond) for AF with rapid ventricular response then give the diltiazem and see if they respond with a decreased rate and decreased CP. If you don't have a special AF protocol, I'd follow your normal SVT protocol (adenosine * 2, cardiovert if unstable).

It was not until after I had some time on the floor in medical school that I have begun to question the significance of the whole 24-48 hour rule. What I have seen is that people spontaneously go into and out of AF all the time, like ALL THE TIME and they don't stroke out. People go into and out of AF several times a day even! Clots can form much faster then 24-48 hours so I don't know exactly how that number was derived and if it is truly significant.

Either way, don't be afraid to let the hospital do their job on complex cardiac patients and manage them. The important things paramedics can do are treat life threatening arrythmias. The only drug on the ambulance that changes outcome in patients with myocardial infarction is asprin (Nitro = no change, MSO4 = may make non-STEMI patients worse, Lidocaine = worse outcome). I actually have yet to see a study that proves prehospital O2 administration helps.

 

[leviathan]

I agree with emdpa.

People in AF have myocardial infarctions too, so for this patient with HR 100-130 it is perfectly appropriate to follow your CP protocol. Actually CAD/MI is a common cause of AF.

If HR > 150 and patient has CP, it could be the rate is causing the chest pain.

If it was rate-related ischemia (or well, ischemia from any cause for that matter), would you not see ST depressions or some signs on the ECG to support this? Still learning here...

 

[viostorm]

If it was rate-related ischemia (or well, ischemia from any cause for that matter), would you not see ST depressions or some signs on the ECG to support this? Still learning here...

Not all ischemia presents with ST-segment changes. Case in point, the non-ST-segment elevation MI (NSTEMI). In fact, the initial ECG has a sensitivity of 50-70% (30-50% false negative rate, ie, you are missing 30-50% of MI's based on ECG alone) and somewhere around 10% of patients with MI have an initial normal ECG.

You are correct that ischemic lesions are often identified by a stress test where heart rate is elevated to 85% maximum and ST segment is monitored throughout. 85% maximum is calculated as (220 - age) * 0.85

ECG is not perfect which is where cardiac enzymes aid in the diagnosis. Troponin is elevated even with the infarction of 1 gram of cardiac tissue.

 

[leviathan]

Not all ischemia presents with ST-segment changes. Case in point, the non-ST-segment elevation MI (NSTEMI). In fact, the initial ECG has a sensitivity of 50-70% (30-50% false negative rate, ie, you are missing 30-50% of MI's based on ECG alone) and somewhere around 10% of patients with MI have an initial normal ECG.

You are correct that ischemic lesions are often identified by a stress test where heart rate is elevated to 85% maximum and ST segment is monitored throughout. 85% maximum is calculated as (220 - age) * 0.85

ECG is not perfect which is where cardiac enzymes aid in the diagnosis. Troponin is elevated even with the infarction of 1 gram of cardiac tissue.

I was referring more to just ischemia rather than an infarct, but I understand your point. If you have CP in the context of afib, you might not see that rate-related ischemic change, or any change, if it was a NSTEMI or unstable angina.

 

[fiznat]

It doesn't sound like chest pain was his primary complaint really. Did it seem to you like more of an afterthought also?

The a-fib I don't think I would have done anything about. Not out of fear of throwing clots, but his rate is not extrordinarly high and his pressure/mentation is fine. If it were a little faster, maybe consider cardizem?

Is the guy currently on coumadin or ASA for his a-fib?

As far as the chest pains, 3-10 is not that impressive. Did he have any of the other cardiac equilivents at all? What was the quality of the pain? Reproducible? What about skin color/temp/condition. Lung sounds, distal edema, etc? If the guy wasn't that impressive of a story + presentation, AND the ECG is clear I don't think I would have even gone with NTG. Probably still ASA cause hey why not.

NSTEMI is fairly rare and without the story, history, or presentation to back it up I would think that the likelyhood of this patient having this condition is very low.

 

[polygonal]

NSTEMI is fairly rare

Based on?......

There is a LOT of bad info on this thread.

I have to agree with MacGyver on this one. If you were in doubt, you should have contacted your medical control. I am a HUGE advocate for EMS, but I can tell you if you had cardioverted this guy or gave him dilt without calling for direction when it was not clearly indicated, I would be upset.

BTW, I think you made the right choice.

 

[Paramedic22]

Thanks for everyone's comments!

To answer fiznat, he was not presenting at all like an MI PT, and his CP was only a 3. Yes, he had called because of the dizziness, and heart fluttering.... During the whole 'do u have any chest pain?' question he said 'actually i guess I do'. He didn't know any of his meds, and they were at his girlfriends' house or something like that.

Anyway, that's why I was confused. His C/C appeared to be a Symptom of the AF but he was stable, his rate wasn't that high, and believed he has a HX of AF.

 

[fiznat]

Based on?......

There is a LOT of bad info on this thread.

Alright I stand corrected, after doing some research it seems the incidence of NSTEMI is higher than I thought, but it did USED to be more rare than it is today. Most every relevant study I found said that NSTEMI incidence is increasing. A quote to that effect from one of the articles:


The incidence of QWMI progressively decreased between 1975/78 (incidence rate = 171/100,000 population) and 1997 (101/100,000 population). In contrast, the incidence of NQWMI progressively increased between 1975/78 (62/100,000 population) and 1997 (131/100,000 population). Hospital death rates were 19.5% for patients with QWMI and 12.5% for those with NQWMI. After controlling for various covariates, patients with QWMI remained at significantly increased risk for hospital mortality (adjusted odds ratio = 1.63; 95% confidence interval: 1.35, 1.97). While the hospital mortality of QWMI has progressively declined over time (1975/78 = 24%; 1997 = 14%), the in-hospital mortality for NQWMI has remained the same (1975/78 = 12%; 1997 = 12%). These trends remained after adjusting for potentially confounding prognostic factors. The multivariable adjusted two-year mortality after hospital discharge declined over time for patients with QWMI and NQWMI.

That is from "Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial q-wave and non-q-wave myocardial infarction: a multi-hospital, community-wide perspective" J Am Coll Cardiol, 2001; 37:1571-1580

Viewed here: http://content.onlinejacc.org/cgi/content/abstract/37/6/1571


Also interesting is the Worcester Heart Attack Study: http://www.nhlbi.nih.gov/meetings/workshops/cvd-events/goldberg_con.htm



So it is not as rare as it used to be, but identification of this syndrome is still very dependent on clinical presentation first, which it seems this patient is markedly low on. I agree that we should probably assume the worst with most potential ACS patients, but does that mean everyone gets MONA across the board out of fear of NSTEMI?

 

[viostorm]

On the ambulance, I treat eveyone with CP protocol (O2, ASA, NTG) who complains of chest pain and is over age of 30 and does not have a readily identifiable alternate cause for their CP (trauma, SVT). ECG does not influence my decision on who to treat (it never should!)Reproducible chest pain on palpation and pain with inspiration/expiration does not exclude a cardiac cause for chest pain.

I'm obviously more agressive on some patients then others based on clinical suspicion. I always keep in mind the only drug that changes mortality in CP I have available on the ambulance is asprin. Those of you with metoprolol may have more complicated decisions.

 

[viostorm]

I have to agree with MacGyver on this one. If you were in doubt, you should have contacted your medical control. I am a HUGE advocate for EMS, but I can tell you if you had cardioverted this guy or gave him dilt without calling for direction when it was not clearly indicated, I would be upset.

Always call for medical direction when patient doesn't fit a protocol well.

But, at the same time I have not seen a study that indicates patients have better outcome when paramedics use online medical control versus standing protocols.

From a practical standpoint of getting along well at work I suggest you follow polygonal's advice, but from an evidence based medicine standpoint I don't think it has been proven. However, I'm not as up to date on the literature as I used to be after 2nd and 3rd year of medical school. I have had to read other things.

I would also suggest the frequency of NSTEMI is increasing because of the sensitivity of the cardiac enzymes. People were having heart attacks we just didn't have a way to detect them. Troponin has just really come on the scene in the last 10 years. It is incredibly sensitive.

 

[polygonal]

I would also suggest the frequency of NSTEMI is increasing because of the sensitivity of the cardiac enzymes. People were having heart attacks we just didn't have a way to detect them.

Bingo. Beat me to it.

Also, as far as EBM and medical control goes (as well as EBM in general), there are no double-blinded placebo controlled studies that demonstrate that parachutes lower mortality from skydiving either. I stand by my statement that paramedics should defer decisions like this to medical control. Further, in my opinion, not doing so may constitute malpractice. I have found personally the more I learn, the less I realized I knew and looking back at some of the things I did as a paramedic frightens me.

 

[Autopulse]

This is a good clinical case, one that is seen daily and it is a teaching case I stress with my Paramedics and my Residents. Essentially there has to be a multifaceted approach because you have to assume that the patient is not suffering from AF/ACS in isolation. Using anectdotal evidence, most of the AF patients we see have a propensity for AF, no matter if it is secondary to ACS/Prior conduction disturbance/ETOH abuse or just old. True, new (never had another episode is rare). Treatment is based no duration.....if it is new,(<48 hours) cardioversion is the treatment, chemical or electrical (in the hospital for stable pts). In real life they all get a TEE before to make sure there is no thrombus or "smoke" in the atrium. Some may get anticoagulated too. If you are unstable treatment is electricity(as you all know). In this case he seems stable. Treating the patient like ACS is absolutly appropriate. I would not have come down on a medic or resident for giving cardizem either, I believe the OP stated the pt had some dizzyness, ?SOB, ?CP but stable vitals.....some folks do not take hr of 130 very well. There are several studies that looked at rate control vs cardioversion and data supports rate control (slowing down the AF and starting warfarin/ASA).....it might be the AFFIRM trial and possible RACE??? That is my general approach, control the rate....if it is 130s+ be prepared that the patients low BP is rate dependent and Fluids and cardizem may do the trick. One teaching point is to make sure you get a good history of things like WPW, because you cannot always see the delta wave as rate increases and WPW + Ca Blockers = Bad

AP

 

[Autopulse]

Polygonal hit the nail on the head.....if I did the things that at times have been acceptable when I was a full time paramedic. As a physician I would never sleep. If you asked me that when I started medical school I would think you were crazy....some of the refusals that were ok to accept, would keep me up all night now if I took one!

Dont' get me started on evidence based EMS