Another ER case

[waterski232002]

Here's an interesting case I had in the ER today....

62 yo M w/ Hx CABG, DM, HTN, ESRD on HD, who was called by his PMD and told to come to the ER for 2/2 + blood cultures for Gram + cocci in clusters. On presentation he had a temp of 40.3, BP 91/50, HR 87, 02 94% RA. He complained of a mild HA and displayed nuchal and back rigidity. I did an LP and administered meningitic doses of antibiotics. His glucose was also noted to be in the 500 club w/ an anion gap of 20, resulting in an insulin gtt. EKG revealed A-flutter w/ 5:1 conduction and ST depressions of 3 mm in leads V3-V6 w/ corresponding TWI's (old EKG was paced). During my exam and LP his pressure was in the 110's; however, about 2 hrs later his BP steadily dropped into the 70's despite 2 liters NS bolus. His 02 sat was 98% on 6L NC, but he denied SOB, CP, and was mentating normally in no apparent distress.

So here's my question.... How would you manage a septic hypotensive patient in A-flutter w/ 5:1 conduction of unknown duration (HR in the 60's)?

---

Members don't see this ad.

 

[southerndoc]

Sync cardiovert. Sometimes a normal physiologic response (tachycardia from sepsis) triggers a pathologic response (a-flutter with 5:1 conduction with subsequent severe diminished diastolic filling secondary to rapid atrial rates).

You could try some norepi, but I would do this after cardioverting. Cardiovert, reassess the pressure, central line and get a CVP, administer fluids to keep his CVP >8-10, and if his MAP is still <60-65, I would start an alpha agonist (norepi). Basically cardiovert and then follow early goal directed therapy on this patient.

 

[waterski232002]

I guess you're not terribly worried about dislodging an atrial thrombus? Also... do you need to worry about atrial thrombi developing in patients w/ AVNRT or AVRT of unknown duration as you do in A-fib/flutter?

 

[BKN]

I guess you're not terribly worried about dislodging an atrial thrombus? Also... do you need to worry about atrial thrombi developing in patients w/ AVNRT or AVRT of unknown duration as you do in A-fib/flutter?

I see no reason to cardiovert somebody with a rate in the 60s. Hypotension is likely due to the sepsis rather than the rhythm. I think follow the Rivers protocol or something near to it. Also draw a cortisol level and give the patient 100 mg hydrocortisone if he doesn't respond to pressors.

 

[waterski232002]

BKN... can you safely cardiovert (sync or pharmacologically w/ adenosine) someone in AVNRT or AVRT of unknown duration without running the risk of dislodging an atrial thrombus? Do atrial thrombi have a tendency to develop in these patients if they are in the rhythm for > 48 hrs?

ACLS guidelines seems to only indentify A-fib/A-flutter as being the culprits for atrial thrombi formation.

 

[NinerNiner999]

I see no reason to cardiovert somebody with a rate in the 60s. Hypotension is likely due to the sepsis rather than the rhythm. I think follow the Rivers protocol or something near to it.

Agreed. I'd start with central line, levo, CVP, IVF, and talk with the family.

 

[margaritaboy]

I see no reason to cardiovert somebody with a rate in the 60s. Hypotension is likely due to the sepsis rather than the rhythm. I think follow the Rivers protocol or something near to it.

[
Agreed. I'd start with central line, levo, CVP, IVF, and talk with the family.

Ditto the above.

Adenosine is unlikely to convert A-flutter or A-fib. If you truely think the patient is unstable secondary to thier cardiac rhythum, then consideration of atrial thrombus takes a back seat to resoring a perfusing rhythum with cardioversion.

In this case, however, I agree with BKN and NinerNiner999. It sounds like the patient is septic and their A-flutter is already rate controled. Address their septic shock with fluids, pressors, antibiotcs, transfusion etc.

 

[BKN]

BKN... can you safely cardiovert (sync or pharmacologically w/ adenosine) someone in AVNRT or AVRT of unknown duration without running the risk of dislodging an atrial thrombus? Do atrial thrombi have a tendency to develop in these patients if they are in the rhythm for > 48 hrs?

ACLS guidelines seems to only indentify A-fib/A-flutter as being the culprits for atrial thrombi formation.

I thought patient was in atrial flutter? Anyway clots form in hypokinetic atria (and ventricles). See no reason for that to happen in atrial tachs.

 

[southerndoc]

I see no reason to cardiovert somebody with a rate in the 60s.

I gotta stop posting so late at night. I didn't catch that. Good grief!

 

[waterski232002]

I thought patient was in atrial flutter? Anyway clots form in hypokinetic atria (and ventricles). See no reason for that to happen in atrial tachs.

The patient was in atrial flutter, and it was for an unknown duration, so we don't know if there are any atrial thrombi present.

I was asking hypothetically about other SVT's like AVRT or AVNRT (unrelated to the above case), if we need to worry about atrial thrombi formation and dislodgement in these rhythms as we do in Afib/flutter.

 

[BKN]

The patient was in atrial flutter, and it was for an unknown duration, so we don't know if there are any atrial thrombi present.

I was asking hypothetically about other SVT's like AVRT or AVNRT (unrelated to the above case), if we need to worry about atrial thrombi formation and dislodgement in these rhythms as we do in Afib/flutter.

I understood. My second sentence was in response. The PATs (now divided into however many things the heart docs like) don't form atrial thrombi because the atria are not hypokinetic.

 

[waterski232002]

Ok... Thanks for the clarification. It just seems strange that A-flutter is categorized w/ A-fib since flutter actually has discrete atrail contractions. Then again, a rate of 300 atrial contractions/minute doesn't give you much forward flow.... mind as well be a fibrillating atrium.