Atrial fibrillation (AFib)

Scott Allen10 said:I missed jumping in on this earlier... it feels a bit "all or nothing" to me. Honestly, the most dangerous complication of FA is actually V-fib. A stroke falls more into a different category; it isn't always directly linked to atrial fibrillation, so I don't think we should label it as the "most dangerous" thing.
The idea that "enlarging the atrium" is directly tied to the onset of AFib isn't quite right either—not sure where that came from. Also, things like shortness of breath or chest pain aren't really hallmarks of AFib itself; those are much more likely signs of myocardial ischemia. A patient with AFib can actually have totally stable hemodynamics with decent blood pressure and good ventricular filling during the cardiac cycle.
With AFib, the real deal is that the atrium doesn't contract; instead, blood just passively flows from the atrium into the ventricle during diastole. Since such a huge chunk of blood moves passively like that anyway, you don't usually run into major hemodynamic issues. Normally, the electrical impulse starts at the SA node and travels through the AV node to trigger the atrial contraction. In AFib, that signal gets hijacked—it fires off in multiple spots all over the atrium randomly, which means the atrium never actually gets that coordinated squeeze.
On an ECG, you'll notice that patients with AFib pretty much lack a P-wave.
It's only if a patient happens to have something else going on, like mitral stenosis that messes with passive filling, that you start seeing real problems with how the pump is working.
The goal with AFib is to try and convert it back to a normal sinus rhythm. Cardioversion can be done with meds, like giving a bolus of amiodarone via IV.
If that doesn't do the trick, you can go the route of electrical cardioversion, or basically defibrillation. We'd put the patient under briefly with something like propofol or ketamine... and you absolutely have to use the synchronized mode on the defibrillator. If you're using a biphasic machine, you wouldn't want to go over 50 - 100 J... you just try a few rounds of cardioversion.
This method works great, but it's definitely most effective if you catch it early.
At the end of the day, every case is different. What works perfectly for one person might not work for another, so the doctor has to make the call on what's best for the situation.

Heh, lol. Must be nice to understand everything so clearly. Looking at this, you're either a doctor, a med student, or just a dedicated researcher like me. Yeah, what you're saying is probably spot on—all the knowledge I'm gathering comes straight from medical encyclopedias, so it's far from exhaustive. I actually enjoy posts like this, Scott Allen10, because I always end up learning something significant. Please, write more often. I'm still waiting to enroll in my program, but once I finish med school, we'll have plenty to debate. Sorry if my post was off; I'm just going by what the textbooks say.🙂🙂

My bad... I really messed that one up. It’s all still a bit too fresh in my mind for me to be making silly mistakes like this... I managed to mix up Rytmonorm (propafenone), which you'd typically use for rapid atrial fibrillation, paroxysmal supraventricular tachycardia, or even paroxysmal ventricular tachycardia, with Cordarone (amiodarone), which is what we look toward for ventricular fibrillation or rhythm issues tied to WPW syndrome, atrial fibrillation, and flutter...

I know, I know—even though epinephrine is the go-to during CPR, when you're actually dealing with ventricular fibrillation or pulseless tachycardia, amiodarone is the move.

cosmicmaker30 said:My bad... I really messed that one up. It’s all still a bit too fresh in my mind for me to be making silly mistakes like this... I managed to mix up Rytmonorm (propafenone), which you'd typically use for rapid atrial fibrillation, paroxysmal supraventricular tachycardia, or even paroxysmal ventricular tachycardia, with Cordarone (amiodarone), which is what we look toward for ventricular fibrillation or rhythm issues tied to WPW syndrome, atrial fibrillation, and flutter...

I know, I know—even though epinephrine is the go-to during CPR, when you're actually dealing with ventricular fibrillation or pulseless tachycardia, amiodarone is the move.

That last part isn't quite right. Epinephrine is the first line of defense in CPR regardless of what the rhythm looks like—whether it's asystole or VF. The only difference is that with VF, you need to hit them with a DC shock first. You keep doing chest compressions for both types of arrest, but with VF, you only pause the compressions long enough to deliver the DC shock... take a quick look at the ECG, and if the fibrillation is still there, get back to compressions, give the epinephrine, and then hit them with another DC shock...
What I'm trying to say is that while ventricular tachycardia is definitely life-threatening and often leads to VF, it’s technically not the same thing as ventricular fibrillation. With VT, if the patient is stable, you can primarily treat them with amiodarone without jumping straight to a DC shock... but VF is a true cardiac arrest situation. There's no time to mess around with amiodarone there, especially not at the start when there isn't even a recognizable rhythm on the ECG.
Lately, vasopressin has been popping up more in resuscitation protocols. Over here, we have it available as Pitressin. In CPR, whether it's asystole or VF, you can start with it by giving a bolus of two ampules of vasopressin (40 units). We've seen some really solid results from it, but it hasn't really become the standard practice in our hospitals yet. Mostly because epinephrine is still considered the "gold standard" and that's what everyone is trained on... but honestly, a huge reason is just that Pitressin is incredibly expensive. Depending on which supplier you use, an ampule can cost hundreds of dollars!
Just a side note: all this talk about "C" (circulation) and "D" (drugs) only matters if you've already handled "A" (airway) and "B" (breathing) right at the start of resuscitation... which, if I'm being honest, doesn't always happen perfectly in our hospital settings... hm... sometimes things get a bit messy...

Andrew Jones12 said:Heh, lol. Must be nice to understand everything so clearly. Looking at this, you're either a doctor, a med student, or just a dedicated researcher like me. Yeah, what you're saying is probably spot on—all the knowledge I'm gathering comes straight from medical encyclopedias, so it's far from exhaustive. I actually enjoy posts like this, Scott Allen10, because I always end up learning something significant. Please, write more often. I'm still waiting to enroll in my program, but once I finish med school, we'll have plenty to debate. Sorry if my post was off; I'm just going by what the textbooks say.🙂🙂

Seriously though, please keep posting about this topic... I live for these resuscitation stories, so there's nothing wrong with having a little discussion now and then.

Especially since I feel like every single healthcare worker, whether they're a doctor or a nurse, needs to have a full grasp on this... rather than having someone like this one anesthesiologist I know who actually tries to shock a flatline during asystole...😲...if I hadn't seen it with my own eyes, I wouldn't have believed it...

Scott Allen10 said:Seriously though, please keep posting about this topic... I live for these resuscitation stories, so there's nothing wrong with having a little discussion now and then.

Especially since I feel like every single healthcare worker, whether they're a doctor or a nurse, needs to have a full grasp on this... rather than having someone like this one anesthesiologist I know who actually tries to shock a flatline during asystole...😲...if I hadn't seen it with my own eyes, I wouldn't have believed it...

Heh, looks like cosmicmaker30 really gets it. We need more forum members like you. Just keep posting about any medical field you want.🙂🙂🙂

Scott Allen10 said:That last part isn't quite right. Epinephrine is the first line of defense in CPR regardless of what the rhythm looks like—whether it's asystole or VF. The only difference is that with VF, you need to hit them with a DC shock first. You keep doing chest compressions for both types of arrest, but with VF, you only pause the compressions long enough to deliver the DC shock... take a quick look at the ECG, and if the fibrillation is still there, get back to compressions, give the epinephrine, and then hit them with another DC shock...
What I'm trying to say is that while ventricular tachycardia is definitely life-threatening and often leads to VF, it’s technically not the same thing as ventricular fibrillation. With VT, if the patient is stable, you can primarily treat them with amiodarone without jumping straight to a DC shock... but VF is a true cardiac arrest situation. There's no time to mess around with amiodarone there, especially not at the start when there isn't even a recognizable rhythm on the ECG.
Lately, vasopressin has been popping up more in resuscitation protocols. Over here, we have it available as Pitressin. In CPR, whether it's asystole or VF, you can start with it by giving a bolus of two ampules of vasopressin (40 units). We've seen some really solid results from it, but it hasn't really become the standard practice in our hospitals yet. Mostly because epinephrine is still considered the "gold standard" and that's what everyone is trained on... but honestly, a huge reason is just that Pitressin is incredibly expensive. Depending on which supplier you use, an ampule can cost hundreds of dollars!
Just a side note: all this talk about "C" (circulation) and "D" (drugs) only matters if you've already handled "A" (airway) and "B" (breathing) right at the start of resuscitation... which, if I'm being honest, doesn't always happen perfectly in our hospital settings... hm... sometimes things get a bit messy...

Sure, epinephrine is used for asystole, VF, pulseless VT, and PEA. But listen to this: when treating VF and pulseless VT, amiodarone is administered as a slow 300 mg bolus, followed by a second dose that's half that size—150 mg IV. At least, that's what one ICU doctor told me. I know because I saw them prescribe that exact regimen for a female patient in VF over in the ICU.

I completely agree—BLS (basic life support) always comes before ALS (advanced life support). What I find really interesting, though, is that according to the latest CPR guidelines, the ratio for compressions to breaths is 30:2. So, 30 chest compressions followed by two breaths...

cosmicmaker30 said:Sure, epinephrine is used for asystole, VF, pulseless VT, and PEA. But listen to this: when treating VF and pulseless VT, amiodarone is administered as a slow 300 mg bolus, followed by a second dose that's half that size—150 mg IV. At least, that's what one ICU doctor told me. I know because I saw them prescribe that exact regimen for a female patient in VF over in the ICU.

I completely agree—BLS (basic life support) always comes before ALS (advanced life support). What I find really interesting, though, is that according to the latest CPR guidelines, the ratio for compressions to breaths is 30:2. So, 30 chest compressions followed by two breaths...

In resuscitation medicine, the idea of giving a drug "slowly as a bolus" doesn't even exist... which makes me pretty skeptical about whether that specific case you mentioned was actually handled correctly. Also, we have to ask—which ICU are we talking about? Honestly, almost every hospital ward has some little corner or room they call "the ICU." But most of the time, it's just a tiny nook with an oxygen tank and maybe a pulse oximeter, if you're lucky...
The term "ICU" gets thrown around so loosely in American hospitals that basically any little storage closet or side room gets slapped with the label, even if there isn't a shred of intense medical activity happening in there...
Sure, maybe that specific example was actually a perfectly handled amiodarone case, but you’d still need DC cardioversion and continuous chest compressions along with proper ventilation and oxygenation... It's just hard to judge a single individual case or the flow of a crisis like that based on one anecdote...
You're spot on regarding those new compression-to-ventilation ratios... It turns out that during resuscitation, the absolute priority is maintaining blood flow through the vessels, and you achieve that through compressions. Doing just one or two breaths for every 30 compressions is plenty to ensure the body gets enough oxygen as that blood is pumped through the system, especially to the brain....
Still, I think those breaths have to be high quality, with a full volume of well-oxygenated air... which brings us right back to the "A" and "B" of the airway and breathing alphabet. You have to secure a safe airway and make sure lung ventilation is sufficient.
And honestly, in the middle of all that chaos during a code, the best way to do that is via endotracheal intubation, which needs to happen ASAP—right in the thick of compressions, DC shocks, and trying to find a vein. Using a mask with an Ambu bag is pretty questionable... Not because it's useless, but because people do it so poorly! You wouldn't believe how incredibly hard it is to ventilate someone using an Ambu bag. If you haven't tried it, you probably can't imagine it, but trying to get a good seal between the mask and the face while performing compressions and dealing with the madness around the bed—all while tilting the head back to keep the airway open so the tongue doesn't block it, and squeezing the Ambu bag at the same time—you have to be seriously skilled. Sometimes it feels like you need an extra hand just to keep up...

Scott Allen10 said:In resuscitation medicine, the idea of giving a drug "slowly as a bolus" doesn't even exist... which makes me pretty skeptical about whether that specific case you mentioned was actually handled correctly. Also, we have to ask—which ICU are we talking about? Honestly, almost every hospital ward has some little corner or room they call "the ICU." But most of the time, it's just a tiny nook with an oxygen tank and maybe a pulse oximeter, if you're lucky...
The term "ICU" gets thrown around so loosely in American hospitals that basically any little storage closet or side room gets slapped with the label, even if there isn't a shred of intense medical activity happening in there...
Sure, maybe that specific example was actually a perfectly handled amiodarone case, but you’d still need DC cardioversion and continuous chest compressions along with proper ventilation and oxygenation... It's just hard to judge a single individual case or the flow of a crisis like that based on one anecdote...
You're spot on regarding those new compression-to-ventilation ratios... It turns out that during resuscitation, the absolute priority is maintaining blood flow through the vessels, and you achieve that through compressions. Doing just one or two breaths for every 30 compressions is plenty to ensure the body gets enough oxygen as that blood is pumped through the system, especially to the brain....
Still, I think those breaths have to be high quality, with a full volume of well-oxygenated air... which brings us right back to the "A" and "B" of the airway and breathing alphabet. You have to secure a safe airway and make sure lung ventilation is sufficient.
And honestly, in the middle of all that chaos during a code, the best way to do that is via endotracheal intubation, which needs to happen ASAP—right in the thick of compressions, DC shocks, and trying to find a vein. Using a mask with an Ambu bag is pretty questionable... Not because it's useless, but because people do it so poorly! You wouldn't believe how incredibly hard it is to ventilate someone using an Ambu bag. If you haven't tried it, you probably can't imagine it, but trying to get a good seal between the mask and the face while performing compressions and dealing with the madness around the bed—all while tilting the head back to keep the airway open so the tongue doesn't block it, and squeezing the Ambu bag at the same time—you have to be seriously skilled. Sometimes it feels like you need an extra hand just to keep up...

Unfortunately, we see similar issues with "intensive care" at my hospital too... over at our surgery department... they have an outpatient clinic and an ER... I don't know what it's like where you are, but even though we're short on gear and equipment, we have an entire floor dedicated to intensive care (well, half a floor) including two shock rooms, two trauma rooms, and three ICU beds staffed by specialized techs... We manage to scrape by...

Yeah... when we're talking about layperson first aid, we can settle for them just tilting the head back... since they're mostly working on instinct and limited knowledge. But when it comes to professional medical help, I completely agree that intubation is much more efficient and lets the provider focus on other things... though I think you really have to master intubation before attempting it. I know people who showed up to a car wreck and didn't even know how to place a tube... but regardless, I'll always take the bag over mouth-to-mouth, since you get about 16% more oxygen that way.

Hey, can someone break this down for me in plain English? I'm looking at this diagnosis:
-Chronic atrial fibrillation with rapid ventricular response

Totally blanked on this one...

When someone’s dealing with AFib and their heart rate starts racing like crazy, we usually say they have AFib with a rapid ventricular response. Basically, it's just AFib paired with tachycardia.

Thanks, but I actually stumbled upon the answer while just sitting around waiting for nothing... hehehe... anyway, here’s another one for you.
You know those AEDs (Automated External Defibrillators)? Which company actually manufactures them?
And I want your take on this... should an EMT really be expected to know drug dosages... or perform defibrillation... things that are usually considered doctor territory?
We had a bit of a debate about this recently. Personally, I think it'd be perfectly fine. If you understand the algorithm and the flow of ALS, you can basically anticipate what the doctor is going to ask for, which lets you move way faster when every second counts.

I would appreciate some guidance on the administration of epinephrine, given its tendency to increase heart rate and the subsequent risk of inducing arrhythmias. Furthermore, one must be cautious regarding cardiac glycosides, as they enhance the activity of the sodium-potassium pump responsible for contractions. In terms of pharmacological options, administering 2% Lidocaine intravenously—or even intracardially during an emergency—seems most appropriate, as it acts directly upon that sodium-potassium pump.

I didn't quite catch what you meant in the first part regarding the adrenaline, so could you maybe dive a bit deeper and give me your take on that?

Honestly, giving drugs intracardially just doesn't make any sense. That whole method is basically ancient history at this point—it felt more like a ritualistic gesture than anything actually effective.

Right before I was supposed to be discharged from the hospital, I suddenly went into atrial fibrillation. Usually, when it happens to me—which is a few times a year—it just resolves on its own within a couple of hours, or sometimes takes a week. This time, the doctors wanted to get it under control immediately. They started with meds: magnesium infusions, Rythmol, and heavy doses of beta-blockers. Based on my past experiences, I had a feeling they wouldn't work, and sure enough, they didn't. So, on the second day, they moved to cardioversion (electrical shock). It went pretty smoothly; the whole thing probably took about 10 to 15 minutes.
Next time, I'm not going to sit around waiting for the fibrillation to clear up on its own.

coastalbison6 said:Right before I was supposed to be discharged from the hospital, I suddenly went into atrial fibrillation. Usually, when it happens to me—which is a few times a year—it just resolves on its own within a couple of hours, or sometimes takes a week. This time, the doctors wanted to get it under control immediately. They started with meds: magnesium infusions, Rythmol, and heavy doses of beta-blockers. Based on my past experiences, I had a feeling they wouldn't work, and sure enough, they didn't. So, on the second day, they moved to cardioversion (electrical shock). It went pretty smoothly; the whole thing probably took about 10 to 15 minutes.
Next time, I'm not going to sit around waiting for the fibrillation to clear up on its own.

Yay, that's how my doctor describes it—just a little "zapping" ☕
I remember spending the entire following day throwing up because of the anesthesia...

Nicole James said:Yay, that's how my doctor describes it—just a little "zapping" ☕
I remember spending the entire following day throwing up because of the anesthesia...

I was only lightly sedated (around 40mg of propofol, I think) and was up and walking right away without any issues.

coastalbison6 said:I was only lightly sedated (around 40mg of propofol, I think) and was up and walking right away without any issues.

I had a short session too, but man, I felt absolutely wrecked afterward. It was not fun at all.