Atrial fib < 48 hours?

[Angry Birds]

Stupid question but how does one determine if someone's A fib is < 48 hrs or not?

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[gman33]

You don't.
Admit and leave to cardiologist.

 

[Angry Birds]

You don't.
Admit and leave to cardiologist.

Hmmm that's what I've been doing but I'm trying to update my firmware and start doing electric cardioversion if less than 48 hours.

 

[Tiger26]

Interrogate their AICD ... (did this once on somebody and therefore essentially transvenously shocked them through their AICD)

Otherwise, they need to have a really, really good story on when they think they've flipped into it. Most of the time it's on people who've had it before who know they're in it again. I'd say it's rare that people have a good enough recollection that I'd consider rhythm controlling them in my current patient population

 

[Janders]

(1) Believe their story. Sometimes I do, sometimes I don't. If they come in with rapid fib at 150, and felt it acutely start 45 minutes ago, its more believable. Also I've met a few savy patients who have iPhone apps or HR monitors and check their rhythm a couple times a day... thus having a log of sinus rhythm!
(2) Some, despite mostly being in sinus, are already anti coagulated. cardiovert away!!!

 

[K31]

Interrogate their AICD ...

Interrogate their FitBit.

 

[Birdstrike]

There's no good way to determine onset of afib precisely, accept with before and after ekg/aicd/rhythm-strip combined with symptoms, as mentioned above. Regardless, there's nothing about rate controlled, stable Afib that's an emergency by itself, so why cardiovert these people?

If they're unstable, then you can cardiovert regardless, and time of onset is irrelevant. I always felt like elective ED cardioversion of afib was pointless.

I'm not sure why anyone does it other than they think it's "fun" and don't mind doing cardiology's job for them, not to mention the majority of true new onset afibs spontaneously revert to sinus within 48 hours, making most of these elective ED cardioversions pointless and unneeded. Millions of people walk around in afib, un-antocoagulated all the time and flip in and out of it and without rapid ventricular response or symptoms, there's no "there" there.

 

[gro2001]

It's true that symptoms are notoriously unreliable for predicting onset and duration of a-fib. However, I suspect (with absolutely no real evidence however), that it's only true on a population level. I've seen quite a few folks who were absolutely convinced they knew exactly when their a-fib started and they convinced me too. Most patients can't really be relied on though.

I do think there is a subset of folks in stable a-fib, anticoagulated or not, who could benefit from cardioversion. Mostly for comfort. Some folks find being in a-fib to be a really unpleasant feeling. If I can get them out of it very safely (say, using the Ottawa agressive protocol), they understand the risks and want me to do it, I see benefit to that. Likewise if they really don't want to be admitted (which is a reasonable thing).

 

[GeneralVeers]

Admit for rate control/cardiology eval and move on to the next patient.

 

[Angry Birds]

There's no good way to determine onset of afib precisely, accept with before and after ekg/aicd/rhythm-strip combined with symptoms, as mentioned above. Regardless, there's nothing about rate controlled, stable Afib that's an emergency by itself, so why cardiovert these people?

I guess the idea is that the longer they stay in Afib, the more the heart wants to revert to that, due to remodeling or what not.

I'm not sure why anyone does it other than they think it's "fun" and don't mind doing cardiology's job for them, not to mention the majority of true new onset afibs spontaneously revert to sinus within 48 hours, making most of these elective ED cardioversions pointless and unneeded. Millions of people walk around in afib, un-antocoagulated all the time and flip in and out of it and without rapid ventricular response or symptoms, there's no "there" there.

This seems to me to be a counter factor: most will convert themselves within 24 hours. But, I guess there is the issue raised above, as well as patient comfort. Having said that, being electrocuted can't be that comfortable either.

 

[KinesiologyNerd]

Interrogate their FitBit.

This is awesome

 

[Rendar5]

If they know time of onset and can still feel it when it's less than 100 (rare, I have this happen once) Or if they're already anti coagulated.

 

[ERDude]

I never cardioverted stable AF in residency or my first job....now I do it all the time b/c it's the culture and standard of practice at our shop. We have a protocol with total buy-in from the ED and cards and the pt's seem to really appreciate it.

If the pt feels confident they know when they are in Afib OR they are therapeutically anti-coagulated we shock and send home. I probably do it at least once a month and sometimes several times a month. Generally don't do it on the older patients (>70-75ish) unless they are otherwise quite healthy and really with-it.

Just goes to show the degree of practice variation.

 

[shookwell]

I shock or chemically cardiovert and send home some a-fib. Mostly young, healthy people with a pretty convincing onset.

 

[hundreddaysoff]

I never cardioverted stable AF in residency or my first job....now I do it all the time b/c it's the culture and standard of practice at our shop. We have a protocol with total buy-in from the ED and cards and the pt's seem to really appreciate it.

If the pt feels confident they know when they are in Afib OR they are therapeutically anti-coagulated we shock and send home. I probably do it at least once a month and sometimes several times a month. Generally don't do it on the older patients (>70-75ish) unless they are otherwise quite healthy and really with-it.

Just goes to show the degree of practice variation.

How well does this reimburse?

 

[dchristismi]

As long as it's not new, they have a damn good story or are already anticoagulated, I'll cardiovert. The vast majority had some problem with being admitted (airfare, family in town, etc) and I was able to talk to their cardiologist/PCP. Still, it's not a frequent occurrence, but it's a huge patient satisfier. We're taking 1-2 every 6 months - not frequently.

 

[Janders]

How well does this reimburse?

CPT 92960 for non-emergent, 92961 for emergent (cardioversion, NOT defibrillation). Bundled with critical care so can't be reported separately. Likely the sedation you provide will be bundled and not separately billable, but this is occasionally variable.

I found this via Dr. Google, a couple years old:
"92960 (Cardioversion, elective, electrical conversion of arrhythmia; external) has a work RVU of 2.25 and a total RVU of 3.63 for a Medicare payment of $123.56 in the facility setting."

Payment shouldn't change your treatment strategy; you'll be compensated for the cardioversion but considering the time it takes, consent, set-up, etc it doesn't really pay better than the other things you could be doing...

 

[fahimaz7]

There's no good way to determine onset of afib precisely, accept with before and after ekg/aicd/rhythm-strip combined with symptoms, as mentioned above. Regardless, there's nothing about rate controlled, stable Afib that's an emergency by itself, so why cardiovert these people?

If they're unstable, then you can cardiovert regardless, and time of onset is irrelevant. I always felt like elective ED cardioversion of afib was pointless.

I'm not sure why anyone does it other than they think it's "fun" and don't mind doing cardiology's job for them, not to mention the majority of true new onset afibs spontaneously revert to sinus within 48 hours, making most of these elective ED cardioversions pointless and unneeded. Millions of people walk around in afib, un-antocoagulated all the time and flip in and out of it and without rapid ventricular response or symptoms, there's no "there" there.

I bet our academic center cardioverts no less than 15 people/week and sends them home.

 

[WilcoWorld]

This is another example of changing practices.

In residency a fib with RVR = automatic admission.

Now I cardiovert (chemical or electrical, depending) and discharge a fib unless there's a good reason NOT to do so.

The other day, when I called for admission of a 70 yo with CP + a fib with RVR of unclear duration who also had new ST depressions (which I know can just be rate-related, but her rate was between 100-110, so I think that's unlikely) the admitting doc was like, "Oh, AND she has ECG changes? Now I see why you want to admit.".

 

[Zebra Hunter]

A lot of these comments made me second guess how I and most in my residency program treat a-fib w/ rvr. We usually search for alternative causes of tachycardia, throw diltiazem at all of them that we believe are primarily afib w/ rvr, d/c if they have known hx of afib and anticoagulated w/ rx for something for rate control (if not already on one) and have them f/u in 1-2 days with cards. We usually end up consulting cards for pts without a hx of afib.

 

[WilcoWorld]

A lot of these comments made me second guess how I and most in my residency program treat a-fib w/ rvr. We usually search for alternative causes of tachycardia, throw diltiazem at all of them that we believe are primarily afib w/ rvr, d/c if they have known hx of afib and anticoagulated w/ rx for something for rate control (if not already on one) and have them f/u in 1-2 days with cards. We usually end up consulting cards for pts without a hx of afib.

That's a very reasonable practice - which part are you second-guessing?

 

[Zebra Hunter]

.

 

[Angry Birds]

The part about giving dilt to everyone regardless of anticoagulation status.

My post is assuming that the A fib is primary, although often it is secondary, in which case treat the cause. Didn't mean to imply otherwise.

 

[shoal]

problem giving dilt to all of them you reduce the rate of conversion after cardioversion in the next days if someone wants to try. i shock a lot more afibers then i did in residency. i cardioverted 2 today to be exact. both were unstable tho

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[GeneralVeers]

90% of the A-fib RVR I see are stable. In fact most are hypertensive. I usually give bolus of 10-20 mg of cardizem, get rate around 100, then start cardizem drip then admit. If you're in a busy ED you don't have time to do much more than that. It's the rare person under 60 that I see with sudden onset A-fib that would be shockable.

 

[RPedigo]

If it's < 48 hours, my practice (after excluding dangerous causes) is 1/2-dose etomidate (0.15 mg/kg) and cardiovert, start patient on aspirin, discharge with close follow-up with regular doctor or cardiology as an outpatient for TTE and further workup. People always say "oh you don't know it's 48 hours" but Stiell, et al. didn't have special magic powers that allowed them to ascertain the exact onset of atrial fibrillation; if they have a good history, it's a good history. I do technically offer them chemical cardioversion first but tell them the statistics (takes an hour and only works just a smidge over half the time) and most of them opt for electrical cardioversion.

 

[Angry Birds]

If it's < 48 hours, my practice (after excluding dangerous causes) is 1/2-dose etomidate (0.15 mg/kg) and cardiovert, start patient on aspirin, discharge with close follow-up with regular doctor or cardiology as an outpatient for TTE and further workup. People always say "oh you don't know it's 48 hours" but Stiell, et al. didn't have special magic powers that allowed them to ascertain the exact onset of atrial fibrillation; if they have a good history, it's a good history. I do technically offer them chemical cardioversion first but tell them the statistics (takes an hour and only works just a smidge over half the time) and most of them opt for electrical cardioversion.

Big disadvantage is how much extra work it is for us ER folk.

 

[emergentmd]

This thread is enlightening to me and surprised how standard of care for Afib is so different. I have worked in 5+ hospitals and never have we cardioverted stable Afib. Its usually, rate control and admit for New Onset. None of my partners cardiovert stable afib. None of the hospitalists every asked me to cardiovert. None of the cardiologist have come to the ED to cardiovert. It is always ADMIT, ECHO, cardiovert.

I have seen so many different standard of care when I finished residency 15+ yrs ago. When I first started working in my community ED, I would

1. Do therapeutic Paracentesis
2. Considered therapeutic thoracentesis

until I figured out that they always get admitted for IR.

I have peritonsillar abscess sent to my ER for ENT eval all the time from outside hospitals and I did it all as a resident. I still do it but some of my partners call in ENT. I still do my own chest tube for stable Pneumos but some admit for CT to do.

I am just so busy during a day, that I would like to do the least amount of procedures as possible. If I did my own cardioversion, that is atleast a 10-15 minutes of work for consent, discussion, cardioversion, etc.

 

[deleted109597]

This is one of those things that will absolutely change as we move forward. How many people have the inn being full on a daily basis? How many more elderly a fib patients are we going to have in 10 years, and how many fewer hospital beds will we have? Of course, the impetus probably won't come from us, it will come from cards/medicine coming down and doing it and discharging them first, then EPs will start doing it.
It's safe. It's easy (although not as easy as ordering dilt and forgetting the patient). This is like a shoulder dislocation level of care basically.

 

[Angry Birds]

This is one of those things that will absolutely change as we move forward. How many people have the inn being full on a daily basis? How many more elderly a fib patients are we going to have in 10 years, and how many fewer hospital beds will we have? Of course, the impetus probably won't come from us, it will come from cards/medicine coming down and doing it and discharging them first, then EPs will start doing it.
It's safe. It's easy (although not as easy as ordering dilt and forgetting the patient). This is like a shoulder dislocation level of care basically.

For pure time allocation, I think this should be consult cardiology who then do the cardioversion in the ER for us.

 

[DeadCactus]

Threads like this make me regret going into EM. Three or more years of training to dump anything remotely fun on a specialist so I have more time to see some BS belly pain in a narcotic addict or someone with the sniffles...

 

[shoal]

totally depends on your patient population. my population does not want to stay in the hospital so ive cardioverted 3 stable afibs with good stories in the last few months. they were grateful and were ready to go home. they also were educated enough to understand the conversation risks benefits and importance of followup. i see this being much more common in thr future

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[Angry Birds]

Threads like this make me regret going into EM. Three or more years of training to dump anything remotely fun on a specialist so I have more time to see some BS belly pain in a narcotic addict or someone with the sniffles...

It's a good point you have, sir.

 

[Hamhock]

How well does this reimburse?

Just bill critical care and document RVR, sedation, airway, cardioversion. For sure this is more than 30 minutes.

 

[coachB]

Threads like this make me regret going into EM. Three or more years of training to dump anything remotely fun on a specialist so I have more time to see some BS belly pain in a narcotic addict or someone with the sniffles...

Which I think is a good reminder to evaluate your priorities and pick your practice environment accordingly. There are places where you can see a reasonable number of patients and not feel like you "don't have time for procedures." You may make slightly less than the guy humping it to see 3 pph, but you will still do well. What makes me even more frustrated is the complete loss of interest in what is actually best for the patient. A lot of benefits to keeping someone out of the hospital, especially an elderly patient. But we've seen from some of these people in this thread that they long ago lost interest in actually doing what was good for patients.

 

[Birdstrike]

I bet our academic center cardioverts no less than 15 people/week and sends them home.

The question is not what your "academic center" does, but what you will do, when its an academic center of just you.

 

[deleted109597]

For pure time allocation, I think this should be consult cardiology who then do the cardioversion in the ER for us.

Similarly, we should consult ortho for the shoulder dislocations. Hell, get anesthesia to do the sedation and you're already done. Except for the patient taking up the bed until those people deem it worthwhile to come down to the pit.

 

[EDParallax]

Our academic residency ... fwiw ... will rate control stable afib with rvr. IV Cardizem or metoprolol with a "Po chaser" then admit to tele floor. Occasionally discharge depending on attending. Can't say I've ever cardioverted a stable patient. Not sure this is the best practice but I've really enjoyed reading the wide practice variation in this forum.

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[Angry Birds]

Similarly, we should consult ortho for the shoulder dislocations. Hell, get anesthesia to do the sedation and you're already done. Except for the patient taking up the bed until those people deem it worthwhile to come down to the pit.

For the head: consult neuro
For the neck: ENT or GI
For the chest: admit to medicine
For the abdomen: ct scan
For the extremities: ortho

(I'm kidding of course. I realize your point and agree with it.)

 

[fahimaz7]

The question is not what your "academic center" does, but what you will do, when its an academic center of just you.

Depends a lot on the group I am joining and the standard at which we practice. Cardioverting patients with a well appreciated time of onset is one of the most satisfying things I do.

Did it twice today.

 

[WilcoWorld]

For the head: consult neuro
For the neck: ENT or GI
For the chest: admit to medicine
For the abdomen: ct scan
For the extremities: ortho

(I'm kidding of course. I realize your point and agree with it.)

I object!

Sometimes you consult Neuro if more than one extremity is involved, AND there's no trauma.

 

[Angry Birds]

I object!

Sometimes you consult Neuro if more than one extremity is involved, AND there's no trauma.

Well, first you consult Medicine to get a good history and go from there.

 

[WilcoWorld]

Well, first you consult Medicine to get a good history and go from there.

Good point. It's always really helpful when Medicine recommends an Ortho and a Neuro consultation.

In those cases, I usually throw in a Cards consult, because these patients inevitably tell someone that they've had chest pain.

 

[shookwell]

Well, first you consult Medicine to get a good history and go from there.

Consult neuro if you want a neuro bed (or a neuro exam)

Good point. It's always really helpful when Medicine recommends an Ortho and a Neuro consultation.

In those cases, I usually throw in a Cards consult, because these patients inevitably tell someone that they've had chest pain.

Medicine can't request consults here. They can ask but we usually say no. You can consult whoever you want after you get the patient, but I'm not consulting anyone I don't want a bed or opinion from.

 

[Angry Birds]

Consult neuro if you want a neuro bed (or a neuro exam)



Medicine can't request consults here. They can ask but we usually say no. You can consult whoever you want after you get the patient, but I'm not consulting anyone I don't want a bed or opinion from.

Doctor, please check your humor level. It is running very low.

 

[WilcoWorld]

Consult neuro if you want a neuro bed (or a neuro exam)



Medicine can't request consults here. They can ask but we usually say no. You can consult whoever you want after you get the patient, but I'm not consulting anyone I don't want a bed or opinion from.

Or wait, were you joking too? Because consulting Neuro for a neuro exam is actually a lot like consulting Medicine to take a history, in which case - touché.