Quimby2

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Reading the shock or not shock post made me think of a case I had as an intern and some of the thoughts i've had on the matter since:

Case: Elderly female comes into the ED with impressive acute pulmonary edema, normotensive, mild tachycardia (120-140's) and mod resp distress. EKG shows afib. No med records, no known meds, no history from patient (can you say, "veternary medicine?).

The thoughts at the time were this: Patient is "relatively" stable; that is, sytolic bp 100-110 and not yet altrered. The afib might be chronic and, in light of the only mild ventricular response, may not soley be responsible for the pulm edema.

What I did at the time: gave the patient dilt and BiPAP. She turned right around and was admitted for a tune-up.

My thoughts now: This seemed a little risky for a few reasons. One, the calcium channel blocker could have tipped her pulm edem over the edge (does it reverese all that quickly with CaCl? Would pre-medicating with CaCl help or be self-defeating?), was the afib really the issue here? Shock and try converting it (embolism risk)? Amioderone (pretty poor response rate with that drug)? A gram of procaine over an hour (would she make it that long)? How about dilt PLUS dopamine prn??

Dive in...
 
D

deleted109597

Premedicationg with CaCl would be self defeating. It would be like giving a massive 3% NS bolus before giving lidocaine (I know, I know).
I wouldn't shock because of the unknown time frame. However, if you could get a good TEE, shocking wouldn't be a bad idea.
 

BKN

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What I did at the time: gave the patient dilt and BiPAP. She turned right around and was admitted for a tune-up.

My thoughts now: This seemed a little risky for a few reasons. One, the calcium channel blocker could have tipped her pulm edem over the edge (does it reverese all that quickly with CaCl? Would pre-medicating with CaCl help or be self-defeating?), was the afib really the issue here? Shock and try converting it (embolism risk)? Amioderone (pretty poor response rate with that drug)? A gram of procaine over an hour (would she make it that long)? How about dilt PLUS dopamine prn??

Dive in...

A Fib with a rate of 120-140 usually doesn't give hypoperfusion unless the patient also has an ischemic cardiomyopathy. So your assumption should be that decreased squeeze is more the problem than excessive rate. Rate related filling problems in a normal heart happen up above 160 bpm.

1. With A Fib. a rate in the 120-140s, an acceptable BP, and an unknown duration, your treatment was exactly standard and correct. No shock until anticoagulated for a while or echoed. Good work. :) But did you do the other stuff for bad squeeze? Diuretics, NTG drip, Morphine? In other words, "a medical phlebotomy."

2. Ca + a Ca channel blocker? Naah! Procainamide would surely depress the patient's heart. Amiodarone possibly the same.

3. If you have a patient who is borderline hypoperfusing, rapid digitalization is the correct response. Docs have been using the stuff for 300 years. Yes it is toxic, but it's the right drug to slow rates while increasing inotropy. The dilt + dopamine might be equivalent and more controllable, but you might be stuck with keeping the patient in the unit until you went ahead and digitialized them anyway or did something very high tech (transplant, infarctectomy, etc).,

4. If the patient is in shock, you may have to try electrical cardioversion in the face of the embolic risk.
 
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BADMD

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My thoughts now: This seemed a little risky for a few reasons. One, the calcium channel blocker could have tipped her pulm edem over the edge (does it reverese all that quickly with CaCl? Would pre-medicating with CaCl help or be self-defeating?),

Actually, it isn't so crazy. Anecdotally, Calcium blunts the blood pressure response, much less than the heart rate response. Several of our critical care pharmacists recommend pretreating borderline hypotensive Afibers with calcium.

There was even a study that looked at this: http://www.ncbi.nlm.nih.gov/entrez/..._uids=15093843&query_hl=1&itool=pubmed_docsum

Calcium chloride before i.v. diltiazem in the management of atrial fibrillation
Kolkebeck T, Abbrescia K, Pfaff J, Glynn T, Ward JA.

"Diltiazem is commonly used to treat atrial fibrillation or flutter (AFF) with rapid ventricular response (RVR). Although it is very effective for rate control, up to an 18% prevalence of reported diltiazem-induced hypotension [defined by systolic blood pressure (SBP) < 90 mm Hg], and a mean of 9.7% hypotension have been reported from several studies totaling over 450 patients. This hypotension may complicate therapy. Our objective was to determine if calcium chloride (CaCl(2)) pre-treatment would blunt a SBP drop after i.v. diltiazem, while allowing diltiazem to maintain its efficacy. A prospective, randomized, double-blind, placebo-controlled study was conducted. Seventy-eight patients with AFF and a ventricular rate of >/= 120 beats per minute were enrolled. Half received i.v. CaCl(2) pre-treatment; the other half received placebo. All patients then received i.v. diltiazem in a standard, weight-based dose. A second dose of CaCl(2) pre-treatment or placebo and diltiazem was given if clinically indicated for additional rate control. Both CaCl(2) and placebo pre-treatment groups had equal lowering of heart rate (p < 0.001). There were no adverse events in the calcium pre-treatment study arm. One patient in the placebo group became paradoxically more tachycardic and apneic after the diltiazem infusion. Although i.v. CaCl(2) seems to be equally safe compared to placebo as a pre-treatment in the management of AFF with RVR, we were unable to find a statistically significant blunting of SBP drop with CaCl(2) i.v. pre-treatment. Until further research determines a benefit exists, we cannot recommend i.v. CaCl(2) pre-treatment before diltiazem in the treatment of AFF with RVR."

It didn't do much to blunt the blood pressure, but it didn't blunt the heart rate response either.
 

roja

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I have seen this twice, where I have had afib's who are borderline hypotense or get a little hypotense with the dilt (my preference). Its a tough battle because if they are really rapid, the hypotension could easily be from the afib and once you correct it, (rate control) the bp will come up. But they might also bottom thier pressure more. I always have two large bore IV's placed (CHF's I am obviously more cautious) with liters hanging. and I have used calcium twice. It actually works great. It does preferentially blunt the bp response and the rate control stays intact.
 

BKN

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we were unable to find a statistically significant blunting of SBP drop with CaCl(2) i.v. pre-treatment. Until further research determines a benefit exists, we cannot recommend i.v. CaCl(2) pre-treatment before diltiazem in the treatment of AFF with RVR."


So what it says is that pretreatment is safe but worthless? Interesting.
 

beyond all hope

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You can use Digoxin with afib in someone with low BP. People forget Digoxin but it works pretty well if you remember it takes at least 30 minutes to kick in.
I usually do exactly what you did, +/- pretreatment with Calcium. If that doesn't work in someone with low BP, I consider a Digoxin load.
 

BADMD

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So what it says is that pretreatment is safe but worthless? Interesting.

This is always the question with EBM. Clinical experiance says one thing and "the study" says something else. The study authors gave calcium or placebo to all comers (n=78) and did not single out those with borderline pressures. 3 of 4 patients with "hypotension" (SBP < 100) started off that way. Only 1 patient became symptomatic and had no significant intervention (and was in the placebo group).

I'd argue that there wasn't a high enough incidence of symptomatic hypotension to make a conclusion. That plus some methodologic problems (throwing out the one patient who became severely hypotensive, requiring rescue therapy in the placebo group due to missing BP measurements, f.e.), make this a pretty useless study, but interesting for illustrative purposes.
 

roja

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Just as a side note, EBM is not ONLY about research. It also encompasses a clinical experience and patient values...
 
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