Two procedures during one sedation?

[Pigg-O-Stat]

I had an interesting case and I'm curious if anyone would have managed it the same as I did.

45 YO M with hx of recurrent shoulder dislocations, p/w anterior dislocation. I was setting him up for sedation/reduction when I noticed he was in a-fib, rate in the 140's. He was initially NSR when her arrived. He admits one prior episode of AF 1 year ago. Not on anticoagulation, but states he checks his rhythm daily on his Apple Watch and has been NSR as of yesterday.

How would you manage the case? Would anyone try to reduce the shoulder and cardiovert with the same sedation?

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[GeneralVeers]

No. Would need separate consents and a good history of the A fib before carioverting. Also fixing the shoulder may resolve the sympathetic stimulation causing the A-fib.

 

[Pigg-O-Stat]

Other hx: During his prior episode of AF, he was hospitalized on a drip for several days without converting, ended up with TEE/cardioversion. No other significant medical history aside from seizures.

 

[gamerEMdoc]

I generally cardiovert paroxysmal afib. Not chronic afib, but the people that rarely go into it, and have a defined time of onset. I usually just do so chemically with oral flecainide. Since you were sedating already, I wouldn’t see why you couldn’t do one sedation, and consent for both procedures.

 

[BoardingDoc]

I generally cardiovert paroxysmal afib. Not chronic afib, but the people that rarely go into it, and have a defined time of onset. I usually just do so chemically with oral flecainide. Since you were sedating already, I wouldn’t see why you couldn’t do one sedation, and consent for both procedures.

What's your approach to this? I have literally never used flecanide.

 

[emergentmd]

I would call cardiology and if they are fine w me doing it, then I would reduce shoulder then cardiovert.

If Cards not OK, then I give a dose of cardizem, sedate, reduce, and see if they cardiovert. If still in AF, then treat as new onset AFib as usual

 

[Pigg-O-Stat]

Also fixing the shoulder may resolve the sympathetic stimulation causing the A-fib.

I thought about this as well, but my gut was telling me he wouldn't convert back easily. And then I'd be stuck admitting or doing a second sedation.

I would call cardiology and if they are fine w me doing it, then I would reduce shoulder then cardiovert.

Its a FSED, no cardiology. Also no procainamide.

 

[emergentmd]

"Its a FSED, no cardiology. Also no procainamide."

Au Contraire. We have all of the specialists avail to discuss cases on bat phone. Amazing how easy it is to get a specialists when they know the pts they are getting are well insured and not train wrecks.

Had a cardiologist came yesterday begging for business. Never happens in the hospital.

If I were really stuck in the boonies and I know there is no potential for clot breaking off, I would give dose of cardizem. Reduce shoulder. If still in Afib, shock him.

 

[Pigg-O-Stat]

Au Contraire. We have all of the specialists avail to discuss cases on bat phone.

Oh, nice. You definitely don't work in Vegas.

 

[emergentmd]

Oh, nice. You definitely don't work in Vegas.

If I did and was single, I would be broke on the poker tables.

 

[Janders]

I convert afib all the time in the ED. Did one today. Did a couple last week.

So if I thought cardioversion was the proper move for the patient, AND I needed to relocate his shoulder, sure… I would combo those up. Uncommon, require consent, but sure.

I’ve ABSOLUTELY combo’d reductions of various fractures/dislocations with laceration repair in one sedation. Uncommon but I know I’ve sedated someone for a chest tube then reduced their ankle once their chest was vent’d. I suppose I’ve sedated someone for a chest tube and ALSO used that sedation to intubate them… but slightly different story

 

[AlmostAnMD]

I generally cardiovert paroxysmal afib. Not chronic afib, but the people that rarely go into it, and have a defined time of onset. I usually just do so chemically with oral flecainide. Since you were sedating already, I wouldn’t see why you couldn’t do one sedation, and consent for both procedures.

Glad to see someone else using flec. Not a lot of us use it. Once you get a handle of the inclusion criteria it's really convenient just to order a drug and ignore the patient rather than take the time to sedate if busy.

 

[gamerEMdoc]

What's your approach to this? I have literally never used flecanide.

If you have Uptodate, lookup “pill in the pocket”. They give a decent run down of all the oral meds you can use for cardioversion. Nearly every EP doc I’ve encountered when discussing potentially cardioverting uses flecainide, so that’s why I usually use it. Its so easy. Single dose of diltiazem (no drip) for initial rate control then give the flecainide which is an oral med, then have the patient just go lay down and watch tv. Takes about 1-2 hours usually. But I honestly have had great success with it. No drips, no sedation. Way easier on staffing.

Many electrophysiologists will have their paroxysmal patients actually try it at home as well.

 

[Jabbed]

If you have Uptodate, lookup “pill in the pocket”. They give a decent run down of all the oral meds you can use for cardioversion. Nearly every EP doc I’ve encountered when discussing potentially cardioverting uses flecainide, so that’s why I usually use it. Its so easy. Single dose of diltiazem (no drip) for initial rate control then give the flecainide which is an oral med, then have the patient just go lay down and watch tv. Takes about 1-2 hours usually. But I honestly have had great success with it. No drips, no sedation. Way easier on staffing.

Many electrophysiologists will have their paroxysmal patients actually try it at home as well.

Do you only do this on patients with prior ECHO and prior cardiac evaluation? It seems somewhat risky doing this on patients with unknown CAD or EF.

 

[MechEDoc]

Having worked locums over a large geographic area, it's my impression that there is a huge variation in whether or not emergency medicine docs will cardiovert Afib in the ER. I trained in a place that routinely did so and it doesn't bother me much to pursue either chemical or electrical cardioversion (on my own discretion, no conversation w/ cardiology). However I recognize that lots of people won't do that and consider that to be the standard of care as well!

 

[BoardingDoc]

If you have Uptodate, lookup “pill in the pocket”. They give a decent run down of all the oral meds you can use for cardioversion. Nearly every EP doc I’ve encountered when discussing potentially cardioverting uses flecainide, so that’s why I usually use it. Its so easy. Single dose of diltiazem (no drip) for initial rate control then give the flecainide which is an oral med, then have the patient just go lay down and watch tv. Takes about 1-2 hours usually. But I honestly have had great success with it. No drips, no sedation. Way easier on staffing.

Many electrophysiologists will have their paroxysmal patients actually try it at home as well.

Very interesting. Standard practice in my neck of the woods is generally to rate control only. I'll cardiovert someone if they are already on thinners and report being compliant with them. In that case, I do it electrically. I like your idea a lot, but I'm looking at the uptodate article and I don't know how I'm going to verify the inclusion criteria in the ED.

Patient can not have any structural heart disease. "For the purpose of this topic, we define it as any condition in which there is a deviation in the size, shape, function, or structure of the atria or ventricles (such as left ventricular hypertrophy or dilated cardiomyopathy). This also includes coronary artery disease."

Do you rely on the patient to tell you if they have any of those things?

The article also mentions that it's used to treat AF "of short duration." I would argue that most patients can't reliably tell you how long they've been in AF. There are obviously exceptions to this rule, but there is a big difference between reading an UTD article and seeing how this is done in practice. Would love to hear more.

 

[Groove]

I had an interesting case and I'm curious if anyone would have managed it the same as I did.

45 YO M with hx of recurrent shoulder dislocations, p/w anterior dislocation. I was setting him up for sedation/reduction when I noticed he was in a-fib, rate in the 140's. He was initially NSR when her arrived. He admits one prior episode of AF 1 year ago. Not on anticoagulation, but states he checks his rhythm daily on his Apple Watch and has been NSR as of yesterday.

How would you manage the case? Would anyone try to reduce the shoulder and cardiovert with the same sedation?

I'd probably interscalene and avoid sedation altogether in a pt that has manifested an abrupt arrhythmia. Once the shoulder is in and he's had some pain meds...I bet the afib would take care of itself as it's probably nociceptive catecholamine mediated. Most does anyway...(70% resolve at 24h and 91% at 48h)

There's been a lot of studies on the early Cardioversion vs delayed and honestly....I don't really feel the need to aggressively cardiovert these people anymore after looking at the data unless they ask me. Plus, if you really want to cover yourself for that small percentage that have embolic complications at 30 days, you have to get buy in from cards and I've found that it's almost impossible for me to get a clinical cardiologist on call to bless a rushed cardioversion over the phone without all the obligatory echo, anti-coagulation for 48 hours, etc.. If you do intend to go this route, you have better luck skipping on call cards and going straight to whoever is on call for EP. The EP guys tend to be more reasonable and can see the benefit in avoiding a wasted admission. Either that or they want to see them in their clinic in the next couple of days for cardioversion there.

The thing you've got going for you in this case is that they were definitely in NSR when they came in, so you could more easily justify a quick cardioversion if you really wanted to go that route. Most pt's have no idea if they've been in afib for less than 2 days. Plenty of studies show that, the numbers are terrible...it's like 50%. Hell, 20% of afib is completely asymptomatic. The problem in your case is that you've got an afib RVR in a person who's adrenals are pumping overtime due to their dislocated shoulder. This is EXACTLY the type of person that is going to resolve their afib in less than 24h begging the question of whether cardioversion is even necessary. I bet if you just let him chill out after you reduced the shoulder and checked back in an hour, he'd be back in NSR minus the singed chest hairs.

 

[turkeyjerky]

In the case the OP described, I'd probably try to do the cardioversion at the same time (or just after) the shoulder reduction. (Assuming the patient is cool w/ it of course, but I'd try to talk him into it). Especially at a freestanding, much better than having to deal with rate control and transferring the patient (it's not a given that he'll spontaneously convert).

I don't feel the need to talk to cards to get their 'blessing' prior to cardioversion. I feel this is firmly w/in our scope of practice.

 

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[lymphocyte]

If you have Uptodate, lookup “pill in the pocket”. They give a decent run down of all the oral meds you can use for cardioversion. Nearly every EP doc I’ve encountered when discussing potentially cardioverting uses flecainide, so that’s why I usually use it. Its so easy. Single dose of diltiazem (no drip) for initial rate control then give the flecainide which is an oral med, then have the patient just go lay down and watch tv. Takes about 1-2 hours usually. But I honestly have had great success with it. No drips, no sedation. Way easier on staffing.

Many electrophysiologists will have their paroxysmal patients try it at home as well.

4.5g IV Mg plus 2mg/kg PO or 1mg/kg flecainide IV works very, very well in otherwise fit and well young people.

I always consider long term anticoagulation if co-morbid in discussion with cardiology depending on the CHADS-VASc, at least for a few weeks post cardioversion, even if the duration was < 48 hours.

 

[Groove]

The PO flecainide stuff is very interesting but it sounds like one of those therapies that I would lump into my impracticality fanny pack next to relistor shots for narcotic induced constipation and glucagon for esophageal food impactions. I hate giving meds that require 1-2 hour observation to dispo while the WR backs up. What's the end goal? Do you guys send them home with more flecainide if they haven't converted? Do you call cards at that point and then admit? Do you consider chemical cardioversion as a fail and then employ electrical cardioversion followed by d/c? If so, that seems like a lot of wasted time.

There is increasing literature in the cardiology world that early and aggressive rhythm control prevents artrial remodeling and slows the natural progression of disease.

Can you link? I would like to read this... I wonder if their definition of "early and aggressive rhythm control" includes routine cardioversion in the ED. I really haven't read a lot of stuff championing this approach in recent years. At best..a "non inferiority study". Then again it's been awhile since I lit searched the topic.

 

[lymphocyte]

The PO flecainide stuff is very interesting but it sounds like one of those therapies that I would lump into my impracticality fanny pack next to relistor shots for narcotic induced constipation and glucagon for esophageal food impactions. I hate giving meds that require 1-2 hour observation to dispo while the WR backs up. What's the end goal? Do you guys send them home with more flecainide if they haven't converted? Do you call cards at that point and then admit? Do you consider chemical cardioversion as a fail and then employ electrical cardioversion followed by d/c? If so, that seems like a lot of wasted time.



Can you link? I would like to read this... I wonder if their definition of "early and aggressive rhythm control" includes routine cardioversion in the ED. I really haven't read a lot of stuff championing this approach in recent years. At best..a "non inferiority study". Then again it's been awhile since I lit searched the topic.

It actually doesn't extend to the ED world, which is why I took it out of my post and stuck to the topic at hand. But the paradigmatic trial about early rhythm control is the the EAST-AFNET 4 trial published just last year in NEJM with over 100 citations already. A lot of the compelling data are quoted in the introduction.

https://www.nejm.org/doi/full/10.1056/NEJMoa2019422

There was indeed a non-inferiority trial published about delayed vs early cardioversion in the emergent setting with follow-up to 4 weeks, but there was 28% crossover in the delayed group with only 212 patients enrolled. I didn't think it was a terribly helpful trial, but my read of the data was that it's reasonable to just bring them back the next day, especially if they're going to be complaint and the practice environment supports it.

https://www.nejm.org/doi/full/10.1056/NEJMoa1900353

As an aside, the one trial I really wish were funded, and that would be immensely helpful in the critical care/emergent setting, would be long term outcomes of "critical illness AF." All those septic, or whatever, patients who end up developing AF -- is there really any benefit to anticoagulation in the short or long term? It's like the type II MI of the EP world.

 

[Pigg-O-Stat]

It's interesting to see how much variability there is in practice when it comes to managing A-fib. I actually had an episode myself a few years ago after a bunch of night shifts. I waited it out for an awful 24 hours, and self converted. But that's a story for another day.

In my case from yesterday, the patient was completely on board with doing both procedures at once. He just wanted to be done and go home. So we consented for both. Gave 150 propofol, got the shoulder in pretty quick, laid him flat with arms at his side, and delivered 100 joules. He converted, we got a repeat EKG, applied the sling, sat him up and waited for him to wake up. It all went surprisingly smooth. Then he walked out happy.

 

[bravotwozero]

It's interesting to see how much variability there is in practice when it comes to managing A-fib. I actually had an episode myself a few years ago after a bunch of night shifts. I waited it out for an awful 24 hours, and self converted. But that's a story for another day.

In my case from yesterday, the patient was completely on board with doing both procedures at once. He just wanted to be done and go home. So we consented for both. Gave 150 propofol, got the shoulder in pretty quick, laid him flat with arms at his side, and delivered 100 joules. He converted, we got a repeat EKG, applied the sling, sat him up and waited for him to wake up. It all went surprisingly smooth. Then he walked out happy.

Well played my friend! Glad it worked out for everyone involved.

As they say, more than one way to skin a cat, and I think you really can deal with this several ways, all of which are suitable .0

 

[southerndoc]

I changed my practice a few months ago when someone said they were sitting at their desk and had extreme palpitations an hour before arrival. AF/RVR. Was fine the day before and in fact exercised without any difficulties whatsoever.

I cardioverted him at 50 J. Young dude in his 40's. I gave him TPA 40 minutes later for his right-sided hemiparesis with confirmed M2 thrombus. TEE on admission showed atrial appendage clots.

That onset within 48 hours is elusive. AF is like HTN. A lot of people just don't feel anything with it. My practice has changed where if they are unstable or cardiology has seen them and want me to cardiovert, then I'll do it. Otherwise, it's rate control.

 

[emergentmd]

It's interesting to see how much variability there is in practice when it comes to managing A-fib. I actually had an episode myself a few years ago after a bunch of night shifts. I waited it out for an awful 24 hours, and self converted. But that's a story for another day.

In my case from yesterday, the patient was completely on board with doing both procedures at once. He just wanted to be done and go home. So we consented for both. Gave 150 propofol, got the shoulder in pretty quick, laid him flat with arms at his side, and delivered 100 joules. He converted, we got a repeat EKG, applied the sling, sat him up and waited for him to wake up. It all went surprisingly smooth. Then he walked out happy.

Thinking about this alittle more you should have shocked him first.
Wonder if the jolt to a relaxed shoulder would have popped his shoulder in and out of AF.

You could have been published!!!!!

“cardio version for anterior shoulder dislocation”.

 

[Pigg-O-Stat]

Thinking about this alittle more you should have shocked him first.
Wonder if the jolt to a relaxed shoulder would have popped his shoulder in and out of AF.

Haha yeah I thought about this.

But I figured if I got the shoulder reduced, and didn't have time to cardiovert, no big deal. But if the reverse occurred, and we got him cardioverted and no time to do the shoulder - that would just be lame.

My bigger concern was that the shoulder would pop out with the shock - was not a problem.

 

[gamerEMdoc]

Do you only do this on patients with prior ECHO and prior cardiac evaluation? It seems somewhat risky doing this on patients with unknown CAD or EF.

Yeah I don't do it in people with new onset afib generally without discussing it with cards. It's only for the people with known paroxysmal "lone" afib. This is obviously a small subset of people. Often times these people come in and ask to be cardioverted.

 

[WilcoWorld]

I had an interesting case and I'm curious if anyone would have managed it the same as I did.

45 YO M with hx of recurrent shoulder dislocations, p/w anterior dislocation. I was setting him up for sedation/reduction when I noticed he was in a-fib, rate in the 140's. He was initially NSR when her arrived. He admits one prior episode of AF 1 year ago. Not on anticoagulation, but states he checks his rhythm daily on his Apple Watch and has been NSR as of yesterday.

How would you manage the case? Would anyone try to reduce the shoulder and cardiovert with the same sedation?

I'd certainly consider doing both in one sedation.

 

[WilcoWorld]

The PO flecainide stuff is very interesting but it sounds like one of those therapies that I would lump into my impracticality fanny pack next to relistor shots for narcotic induced constipation and glucagon for esophageal food impactions. I hate giving meds that require 1-2 hour observation to dispo while the WR backs up. What's the end goal? Do you guys send them home with more flecainide if they haven't converted? Do you call cards at that point and then admit? Do you consider chemical cardioversion as a fail and then employ electrical cardioversion followed by d/c? If so, that seems like a lot of wasted time.



Can you link? I would like to read this... I wonder if their definition of "early and aggressive rhythm control" includes routine cardioversion in the ED. I really haven't read a lot of stuff championing this approach in recent years. At best..a "non inferiority study". Then again it's been awhile since I lit searched the topic.

Sounds like you work in that rare thing - a functional hospital where your patients don't board.

If I can dc someone in 2 hours it's way better for flow than if I need to admit them, because they'll wait > 2 hours for a bed unless it happens to be Sunday morning.

 

[WilcoWorld]

This all ignores the fact that, since I learned the Cunningham method, I only need to sedate about 10% of my dislocations to reduce a shoulder.

 

[gamerEMdoc]

This all ignores the fact that, since I learned the Cunningham method, I only need to sedate about 10% of my dislocations to reduce a shoulder.

I had the cunninham method work several times when I first learned it, but though I still try it, I havent had it work in years sadly.

 

[emergentmd]

I try to practice what is community standard. I have learned to not go outside of this for many reasons. Most of my sites, cards almost never want me to cardiovert in the ER and staff hates doing conscious sedation. Some of our sister sites cardiovert and some do not in the ER. Same thing w/ peritonsillar abscesses, We get ER to ER transfers from sister sites so I can Drain/steroids/DC.

When I came out of residency I did abd paracentesis and thoracentesis in the ER. After about 6 months and figuring out I was the only one to do it, why take on the liability?

 

[MechEDoc]

I changed my practice a few months ago when someone said they were sitting at their desk and had extreme palpitations an hour before arrival. AF/RVR. Was fine the day before and in fact exercised without any difficulties whatsoever.

I cardioverted him at 50 J. Young dude in his 40's. I gave him TPA 40 minutes later for his right-sided hemiparesis with confirmed M2 thrombus. TEE on admission showed atrial appendage clots.

That onset within 48 hours is elusive. AF is like HTN. A lot of people just don't feel anything with it. My practice has changed where if they are unstable or cardiology has seen them and want me to cardiovert, then I'll do it. Otherwise, it's rate control.

I think this anecdotally illustrates how rare the likely point (in time) prevalence of a clinically significant atrial clot is in someone with a-fib.

1. Patients are terrible historians as to how long they have been in afib.
2. Historical practice practice has been that it is "safe" to cardiovert patients at up to 48 hours of afib.
* the 48 hours was arbitrary. To my knowledge, 72 hours, 96 hours or some other cutoff could easily be as safe, it's just never been adequately studied.
* given the lack of reliable a-fib duration data and historical pattern of "cardioversion up to 48 hours based upon history", we've probably been cardioverting lots of people > 48 hours with a low rate of stroking. However, pursuing this approach does lead to some risk. However, I'm not sure if this risk is much different from rate controlling, anticoagulating, and sending home (where a large amount will likely convert to NSR in the next 24-72 hours and they will still likely have a clinically significant atrial clot.

 

[AlmostAnMD]

Found some cunningham method videos on youtube

that looks like voodoo

More on point of the topic, I'll only offer cardioversion (juice or flec if inclusion criteria met and I'm busy, would rather board longer than do a sedation when getting 3+ PPH) if patient is already known to have afib and states they are RELIABLY taking blood thinners. Otherwise they go to next day afib clinic and a script for DOAC and rate control

 

[WilcoWorld]

Found some cunningham method videos on youtube

that looks like voodoo

More on point of the topic, I'll only offer cardioversion (juice or flec if inclusion criteria met and I'm busy, would rather board longer than do a sedation when getting 3+ PPH) if patient is already known to have afib and states they are RELIABLY taking blood thinners. Otherwise they go to next day afib clinic and a script for DOAC and rate control

It takes the right patient - if they cant cooperate, it wont work. The doc isn't really doing much more than coaching. I think of it as doing yoga to "invite the humeral head into the glenoid" by getting the patient to pull their scapula posteriorly.

 

[RoyBasch]

I generally rate control unless unstable.

But occasionally I will do a DCCV in a stable patient. A patient who is already chronically anticoagulated with good compliance, may or may not have a recent TEE that is clean for thrombus, and otherwise seems like a bad candidate for more rate control (soft pressure), I think electricity is a good choice.

Random new onset AF, bad compliance, questionable history: no DCCV.

As other posters above have stated, I think you shouldn't "just do it" because you are already sedating the patient. The decision to sedate or not sedate is not the determining variable. It is whether or not the patient should have a DCCV.

You need to consider whether DCCV is the best choice for the patient independent of the other procedure. As other posters have noted, this is a separate procedure with a different consent, that does have a different set of risks, benefits, and alternatives.

If you have a patient who truly needs two procedures that are both painful, by all means do them during the same sedation, but I think those situations are fairly few and far between.

More common is probably with a poly trauma patient who needs multiple trauma-related procedures (reductions, chest tube, laceration, etc.)

 

[Mushdoc]

The studies that looked at the safety of 12, 24 or 48 hour cardioversion used patient reported data and still found its safe. Its not like these were done with fit-bits. So if the patient reports palpitations or symptoms at a specific time that is good enough for me, because thats what they would have used in the trials. On the other hand if they have no idea, then they have no idea