What would you do?

[dhb]

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So here's what happened on friday:

At 6pm we are ready for an add on ankle fracture, 60 yo woman 200lb we roll her in the or and she's sort of freaking out: scared of falling off the table / slightly confused disorientated.

I put the scope on and rhythm is irregular 120's but she's not aware of having AF, she said she has been on b-blockers for 20y for HTN no anti-coagulant. I look into her chart: nothing apart from the note from the ER when she came in 3 days ago were she was already in a-fib and started on lovenox 80mg bid.

Plan was a spinal so i tell the attending and he's like ok then put her to sleep when i come back her rhythm is now between 130 and 170...

What do you do?

 

[Skrubz]

are you asking about the rate? i agree whole-heartedly with the GA given the enoxaparin.

i'm assuming still in a-fib... how is her pressure with her rate that high? if she's hypotensive, then i'd say that you can't be blamed for cardioverting her. better to have a thromboembolic stroke from a LA thrombus and still be alive than to be dead from having no pressure.

if she's holding her own from a hemodynamic standpoint, i would just try to rate control with beta-blockers. yes, she's been on enoxaparin for 3 days now but unless there's an echo documenting no LA thrombus, i would only try cardioversion (or pharmacologic rhythm-control with amio) if she was unstable.

any other takers?

 

[VentdependenT]

Once those Leads went on and she was in a-fib with NO NOTE from a cardiologist EVEN THOUGH she's being anticoagulated then I'd just say f-this. I'm sure she has many other risk factors for CAD. I bet she has low exercise tolerance (big surprise right) even though she can't quantify it because of her ankle or OA or hip disease or whatever anatomic disability.

Low risk case. Mod risk patient most likely (dm?, tobacco?, post menopausal, obese (I know its not an individual RF but it brings all sorts of crap with it), htn?, high colesterol?, Family hx?, tachycardic with NO RATE CONTROL..wtf man, cp/sob with light exercise?, etc..).

If she has an ekg and it was a-fib before and a cards guy talked to her about it, no problem. SOme kind of cardiac workup in the past few years that was neg, no problem. However with "new" change in cardiac rhythm contact a cards guy on the phone real quick, admit her (yup), have cards see her that day, do what they gotta do, then go for surgery tomorrow or next day.

Although the surgery would probably be ok, and there are TONS of folks walking around with a-fib and no problems, she still needs an initial visit with yer local cardiologist. If not for the surgery, for her own damn benifit.


Now you ask what would I do after walking in on my tachycardic patient?

Rule out Hypoxia, hypercarbia, and light ga (or des cranked through the roof), in about 5 seconds. Meanwhile I'd be pushing esmolol first, giving more oxygen, tappen in fentanyl, and watching the ST's.

If the sbp was low (70's) I'd be pretty f'n pissed off. Unstable SVT? You know the drill.


There is no way in hell I'm putting a spinal in her unless shes been off lovenox for more than 24 hours. Thats a WHOPPER dose. Basically its a PE treatment dose.....

Whats wrong with an ankle block? If they gotta turnicate then Fem-Pop block. GA is fine for her but what the hell. I love sticken folks with needles.

 

[Planktonmd]

So here's what happened on friday:

At 6pm we are ready for an add on ankle fracture, 60 yo woman 200lb we roll her in the or and she's sort of freaking out: scared of falling off the table / slightly confused disorientated.

I put the scope on and rhythm is irregular 120's but she's not aware of having AF, she said she has been on b-blockers for 20y for HTN no anti-coagulant. I look into her chart: nothing apart from the note from the ER when she came in 3 days ago were she was already in a-fib and started on lovenox 80mg bid.

Plan was a spinal so i tell the attending and he's like ok then put her to sleep when i come back her rhythm is now between 130 and 170...

What do you do?

I am curious: Was that your first encounter with the patient?
You guys don't have a holding area where you meet the patient and maybe control her pain and anxiety before taking her to the OR?
If you take me to the OR without seeing my anesthesiologist my heart rate will be 130 too.

 

[Noyac]

Well I'd feel obligated to treat the problem. B-bockers, Digoxin til she started seeing an aura, or ca channel blockers. If unstable, well you know the drill.

 

[johankriek]

So here's what happened on friday:

At 6pm we are ready for an add on ankle fracture, 60 yo woman 200lb we roll her in the or and she's sort of freaking out: scared of falling off the table / slightly confused disorientated.

I put the scope on and rhythm is irregular 120's but she's not aware of having AF, she said she has been on b-blockers for 20y for HTN no anti-coagulant. I look into her chart: nothing apart from the note from the ER when she came in 3 days ago were she was already in a-fib and started on lovenox 80mg bid.

Plan was a spinal so i tell the attending and he's like ok then put her to sleep when i come back her rhythm is now between 130 and 170...

What do you do?

give her a beta blocker and move on with your life


shes prolly been in th ehospital for a bit and nobody gave her the right medicine
if she is hypotensive hit her with some neo that should raise the bp and reflexly lower the hr. I agree 130 is too high but i would accept 105-109 with an acceptable pressure without getting too crazy. OF course if you have to cardiovert do it.. but usually not necessary...

 

[IceDoc]

Well I'd feel obligated to treat the problem. B-bockers, Digoxin til she started seeing an aura, or ca channel blockers. If unstable, well you know the drill.

Digoxin? I didn't know they still made that stuff.
If I want to start converting the rhythm (which for this case I probably wouldn't, just control the rate with B-blocker of choice or, my favorite, Diltiazem), then Amiodarone is my drug of choice.

How do y'all feel about sticking needles (peripheral blocks) with the Lovenox on board?

 

[dhb]

So i'll try to answer some questions:

BP was stable in the 130's systolic O2 sat was in the high 90's hypercarbia? don't know didn't take a blood gas.
No we don't have a holding area we see patients the day before and the floor nurses give the their pre-medication but in this case the patient had not been seen by an anesthesiologist.

So the attending says lets give her amiodarone so i say well through a 20g on the inner part of her forearm it's not going to bode well. So he says put in a central line... so i say well she's been on lovenox for 3days but how do we know there's not a thrombus ready to shoot out. He says call card get them to treat the patient.

I wanted to give her digoxin to control her rhythm and not convert her before further work up, i call the cardiologist who tells me the same thing.

Would you go through with the case if you achieve rate control? We canceled.

Is there anything else that you would think of? what could be the cause of the a-fib?

 

[VentdependenT]

So i'll try to answer some questions:

BP was stable in the 130's systolic O2 sat was in the high 90's hypercarbia? don't know didn't take a blood gas.
No we don't have a holding area we see patients the day before and the floor nurses give the their pre-medication but in this case the patient had not been seen by an anesthesiologist.

So the attending says lets give her amiodarone so i say well through a 20g on the inner part of her forearm it's not going to bode well. So he says put in a central line... so i say well she's been on lovenox for 3days but how do we know there's not a thrombus ready to shoot out. He says call card get them to treat the patient.

I wanted to give her digoxin to control her rhythm and not convert her before further work up, i call the cardiologist who tells me the same thing.

Would you go through with the case if you achieve rate control? We canceled.

Is there anything else that you would think of? what could be the cause of the a-fib?

She's asleep, done deal. I'd go through the case if her BP was not in the dumper. I'd give ESMOLOL to nab the rate control immediately.

Amiodarone for any tachycardia is a safe bet. How much you gonna give? How fast? Could you start a larger IV, or an EJ, and give it there? I personally wouldn't care and if I had to I'd push it through the PIV. Excuse my ignorance but what happens if you push it through PIV (can't remember. Only time I give amiodarone is if the poops hittin the fan, which so far has only been on the floors, and I don't care where the IV is)? Skin necrosis with extravasation?

Myraid causes of a-fib. From thryoid disorders, to cad, to an overdistended atria from any valve disorder, copd, blah blibbidly blah.

 

[UTSouthwestern]

She's asleep, done deal. I'd go through the case if her BP was not in the dumper. I'd give ESMOLOL to nab the rate control immediately.

Amiodarone for any tachycardia is a safe bet. How much you gonna give? How fast? Could you start a larger IV, or an EJ, and give it there? I personally wouldn't care and if I had to I'd push it through the PIV. Excuse my ignorance but what happens if you push it through PIV (can't remember. Only time I give amiodarone is if the poops hittin the fan, which so far has only been on the floors, and I don't care where the IV is)? Skin necrosis with extravasation?

Myraid causes of a-fib. From thryoid disorders, to cad, to an overdistended atria from any valve disorder, copd, blah blibbidly blah.

As a side note, beware of giving amiodarone and esmolol or any beta blocker in close time proximity in large amounts. I and my partners have seen patients go completely asystolic. If you plan to give both in succession or concurrently, titrate them in SLOWLY or you could be in for a very fun case.

 

[Planktonmd]

So i'll try to answer some questions:

BP was stable in the 130's systolic O2 sat was in the high 90's hypercarbia? don't know didn't take a blood gas.
No we don't have a holding area we see patients the day before and the floor nurses give the their pre-medication but in this case the patient had not been seen by an anesthesiologist.

So the attending says lets give her amiodarone so i say well through a 20g on the inner part of her forearm it's not going to bode well. So he says put in a central line... so i say well she's been on lovenox for 3days but how do we know there's not a thrombus ready to shoot out. He says call card get them to treat the patient.

I wanted to give her digoxin to control her rhythm and not convert her before further work up, i call the cardiologist who tells me the same thing.

Would you go through with the case if you achieve rate control? We canceled.

Is there anything else that you would think of? what could be the cause of the a-fib?

She is now on the OR table, anxious, scared, and in pain, here is what I would do:
1- Send the surgeons to the lounge for another cup of coffee.
2- Get a good peripheral IV.
3- Give some Midazolam and some Fentanyl while reassuring the patient.
4- If the Heart rate is still high give small doses of Verapamil (less than 5 mg might be enough).
5- once the heart rate is under control and the patient is more relaxed do a femoral nerve block and a popliteal block (or sciatic if you prefer).
6- Run a little Propofol drip and get the case done.

 

[dhb]

She is now on the OR table, anxious, scared, and in pain, here is what I would do:
1- Send the surgeons to the lounge for another cup of coffee.
2- Get a good peripheral IV.
3- Give some Midazolam and some Fentanyl while reassuring the patient.
4- If the Heart rate is still high give small doses of Verapamil (less than 5 mg might be enough).
5- once the heart rate is under control and the patient is more relaxed do a femoral nerve block and a popliteal block (or sciatic if you prefer).
6- Run a little Propofol drip and get the case done.

Good plan, 2-not possible i agree with the rest but what about the cause of the a-fib, could be an MI, PE, heart failure, infection/sepsis there was also a question mark in the ER note about alcohol abuse and i was thinking she could be starting a DT.

"Excuse my ignorance but what happens if you push it through PIV"
Well it's very irritant i can tell you first hand! Plus i would wan t to convert to sinus someone in a-fib for who knows how long

 

[jetproppilot]

She is now on the OR table, anxious, scared, and in pain, here is what I would do:
1- Send the surgeons to the lounge for another cup of coffee.
2- Get a good peripheral IV.
3- Give some Midazolam and some Fentanyl while reassuring the patient.
4- If the Heart rate is still high give small doses of Verapamil (less than 5 mg might be enough).
5- once the heart rate is under control and the patient is more relaxed do a femoral nerve block and a popliteal block (or sciatic if you prefer).
6- Run a little Propofol drip and get the case done.

I really like verapamil.

Its not "vogue" anymore since higher-priced drugs solicited by good looking drug reps have taken over the tachycardia market, but it works great for a situation like this.

 

[Planktonmd]

Good plan, 2-not possible i agree with the rest but what about the cause of the a-fib, could be an MI, PE, heart failure, infection/sepsis there was also a question mark in the ER note about alcohol abuse and i was thinking she could be starting a DT.

"Excuse my ignorance but what happens if you push it through PIV"
Well it's very irritant i can tell you first hand! Plus i would wan t to convert to sinus someone in a-fib for who knows how long

My first differential for the Afib would be acute pain and fear in a patient who has undiagnosed paroxysmal A Fib.
All the other things you mentioned are possible and maybe should have been addressed earlier, but that does not change the fact that this woman has a broken ankle that needs surgery, she is now in the OR and for the next few hours she will be as closely monitored as she could ever be, she will be monitored by an anesthesiologist 1/1, what better situation can she ask for?? 😀

About the IV, If your #20 is running nicely there is no problem giving Verapamil through it.
I wouldn't use Amiodarone in this woman and my goal would be rate control not sinus Rhythm, although she might go back to sinus once she is less scared.

 

[Planktonmd]

I really like verapamil.

Its not "vogue" anymore since higher-priced drugs solicited by good looking drug reps have taken over the tachycardia market, but it works great for a situation like this.

Hey,
welcome back!

 

[invitro]

Correct me if I am wrong, but wouldn't diltiazem be a better choice than verapamil in this case? Drawing back to my pharm class 2nd year, doesn't diltiazem work mostly on cardiac Ca channels and verapamil work more on the peripheral vasculature? Come to think of it, I am pretty sure I remember reflex tachycardia being more associated with verapamil.

I just remember using Cardizem(dilitiazem) much more in the CCU than Norvasc(verapamil).

Not to be picky, but just was wondering. On the other hand as a lowly CA-1, I defer to the more enlightened attgs/upper-levels recs about this.

Also as a side note, for the stylingest techno beats I prefer http://store.ultrarecords.com/.
Check out Sorry (Dirty South remix)....I could dance to this for hours.....

 

[Planktonmd]

Correct me if I am wrong, but wouldn't diltiazem be a better choice than verapamil in this case? Drawing back to my pharm class 2nd year, doesn't diltiazem work mostly on cardiac Ca channels and verapamil work more on the peripheral vasculature? Come to think of it, I am pretty sure I remember reflex tachycardia being more associated with verapamil.

I just remember using Cardizem(dilitiazem) much more in the CCU than Norvasc(verapamil).

Not to be picky, but just was wondering. On the other hand as a lowly CA-1, I defer to the more enlightened attgs/upper-levels recs about this.

Also as a side note, for the stylingest techno beats I prefer http://store.ultrarecords.com/.
Check out Sorry (Dirty South remix)....I could dance to this for hours.....

Wrong.
Norvasc = Amlodipine not Verapamil.

Verapamil slows the heart like diltiazem but it's long acting and more potent, you don't need a drip with Verapamil.
No reflex tachycardia with verapamil.

 

[invitro]

Whoops. Next time I better double check my epocrates before posting....😳

 

[tussionex]

Whoops. Next time I better double check my epocrates before posting....😳

or consult your friendly pharmacist! 🙂

 

[proclivity]

or consult your friendly pharmacist! 🙂

did you take that picture of the lady bug?

 

[dhb]

My first differential for the Afib would be acute pain and fear in a patient who has undiagnosed paroxysmal A Fib.
All the other things you mentioned are possible and maybe should have been addressed earlier, but that does not change the fact that this woman has a broken ankle that needs surgery, she is now in the OR and for the next few hours she will be as closely monitored as she could ever be, she will be monitored by an anesthesiologist 1/1, what better situation can she ask for?? 😀

I understand your point but aren't you exposing yourself to litigation if anything happens: stroke, Mi, PE?

So we rolled her back to the PACU and i gave her 0.5mg of digoxin which didn't have a tremendous effect her HR went from 140-150's to 120-130's

 

[sdn1977]

Wrong.
Norvasc = Amlodipine not Verapamil.

Verapamil slows the heart like diltiazem but it's long acting and more potent, you don't need a drip with Verapamil.
No reflex tachycardia with verapamil.

Agree here & with Jet. Its a nice drug. The "problems" you may have encountered when in med school, in vitro, might have been with issues when they tried drips in the CCU - its hard to do because of lots of incompatibilities, even with the plastic IV containers.

Pushing it is the best - just push it a bit slower than you might somthing else & DON'T push it into an IV that has bicarb or anything which might bring the pH above 6 - it precipitates immediately into a crystalline structure which you can see in a tube (which you might not see since you're pushing it so close to the hand/arm/whatever)...but, you might lose your line because of it. Run the IV well first, push & run at least 5ml before pushing anything else. When nurses push it in an ICU setting, they can actually see the precipitate which can vary from a clear crystalline structure to a white fine precipitate depending on what drug they're inadvertently pushing it into.....and - they always lose the line.

There might be a little "irritation" since the pH is so low, but its transient & not something that is remembered, especially if you've given midazolam, which I think you did.

So...you loaded dig with a mild response post-op. Now did the cardiologists take over, dhb???

Just curious what happened after, if you know.

 

[tussionex]

no, i didn't take the ladybug picture...i wish!
i'm boning up on my photo skills, but i'm not there yet...and lacking a macro lens 🙂

i agree with sdn1977; verapamil is "fussy" but a good choice. i tell our nurses to flush well, push, and flush again before running anything else when they push any of the more temperamental drugs.

 

[BLADEMDA]

Once those Leads went on and she was in a-fib with NO NOTE from a cardiologist EVEN THOUGH she's being anticoagulated then I'd just say f-this. I'm sure she has many other risk factors for CAD. I bet she has low exercise tolerance (big surprise right) even though she can't quantify it because of her ankle or OA or hip disease or whatever anatomic disability.

Low risk case. Mod risk patient most likely (dm?, tobacco?, post menopausal, obese (I know its not an individual RF but it brings all sorts of crap with it), htn?, high colesterol?, Family hx?, tachycardic with NO RATE CONTROL..wtf man, cp/sob with light exercise?, etc..).

If she has an ekg and it was a-fib before and a cards guy talked to her about it, no problem. SOme kind of cardiac workup in the past few years that was neg, no problem. However with "new" change in cardiac rhythm contact a cards guy on the phone real quick, admit her (yup), have cards see her that day, do what they gotta do, then go for surgery tomorrow or next day.

Although the surgery would probably be ok, and there are TONS of folks walking around with a-fib and no problems, she still needs an initial visit with yer local cardiologist. If not for the surgery, for her own damn benifit.


Now you ask what would I do after walking in on my tachycardic patient?

Rule out Hypoxia, hypercarbia, and light ga (or des cranked through the roof), in about 5 seconds. Meanwhile I'd be pushing esmolol first, giving more oxygen, tappen in fentanyl, and watching the ST's.

If the sbp was low (70's) I'd be pretty f'n pissed off. Unstable SVT? You know the drill.


There is no way in hell I'm putting a spinal in her unless shes been off lovenox for more than 24 hours. Thats a WHOPPER dose. Basically its a PE treatment dose.....

Whats wrong with an ankle block? If they gotta turnicate then Fem-Pop block. GA is fine for her but what the hell. I love sticken folks with needles.

They are teaching you the right things in Chicago. But, in the private practice world at least think TWICE about PNB's if the patient is on HIGH DOSE LOVENOX. The benefit must justify the risk. I would consider a Popliteal block for post op pain but because of her confusion and obesity an endotracheal tube looks like the wiser move.

You are correct about her A.Fib. I have seen this about a dozen times in my career as described here. If urgent or emergent take a look at her heart yourself, rate control, possible a-line and do the case. If elective Cards. note/ input then still proceed as above.



Blade

 

[dhb]

So...you loaded dig with a mild response post-op. Now did the cardiologists take over, dhb???

Just curious what happened after, if you know.

Yes when he saw her rate was 90-100 and he bumped up her b-blocker

Looking back at her chart her ethanol was 3.5g/l when she was admitted, that's beer not plasma. Would you do the case if your suspecting DT?

 

[Planktonmd]

Yes when he saw her rate was 90-100 and he bumped up her b-blocker

Looking back at her chart her ethanol was 3.5g/l when she was admitted, that's beer not plasma. Would you do the case if your suspecting DT?

She has a broken ankle that needs to be fixed.
If she is in fully blown DT's (which is not the case) you intubate her (doing her a favor) and do the case then send her to the unit with a tube.

 

[Idiopathic]

Id actually feel better about doing this case if it were confirmed/suspected DT's. Intubate, big benzo doses.

"I wanted to give her digoxin to control her rhythm and not convert her before further work up"

Im assuming you mean rate not rhythm? I would have gone CCB first, since dig is not as effective acutely and when catecholamines are increased. I wonder why you guys were kicking around amiodarone and dig in this situation when verapamil/dilt is perfectly reasonable (as is IV beta blockade).

 

[johankriek]

I really like verapamil.

Its not "vogue" anymore since higher-priced drugs solicited by good looking drug reps have taken over the tachycardia market, but it works great for a situation like this.

verapamil is a great drug.. pretty much the only indication for the drug is this exact scenario... not a good choice for hypertension because of the av nodal effects..

 

[Idiopathic]

I think its actually the drug of choice in this scenario...well, in emergency scenarios at least.

 

[dhb]

Im assuming you mean rate not rhythm? ).

Yes rate, the attending was thinking about amiodarone because it's the easy choice when you have an arrhythmia (i guess since it was not a good choice) dig is used commonly here for af but i agree that verapamil or diltiazem are good choices.