Boatswain2PA Posted April 19, 2013 Author Share Posted April 19, 2013 OK. That sums up my understanding before that presentation, thank you! Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 19, 2013 Moderator Share Posted April 19, 2013 no one in vfib is talking. do you mean afib with rapid ventricular response? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 19, 2013 Moderator Share Posted April 19, 2013 no one in vfib is talking. do you mean afib with rapid ventricular response? Link to comment Share on other sites More sharing options...
rcdavis Posted April 19, 2013 Share Posted April 19, 2013 no one in vfib is talking. do you mean afib with rapid ventricular response? Thank you, finally. Link to comment Share on other sites More sharing options...
rcdavis Posted April 19, 2013 Share Posted April 19, 2013 no one in vfib is talking. do you mean afib with rapid ventricular response? Thank you, finally. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted April 19, 2013 Author Share Posted April 19, 2013 no one in vfib is talking. do you mean afib with rapid ventricular response? Yes. I guess the point if this part of his presentation was that WPW in A-fib w/rvr can go so fast that it can LOOK like V-fib (fast, wide, &irregular), yet they are still talking to you so they CAN'T actually be in V-Fib, so treat them like they are in wide complex V-tach (Amiodarone). Link to comment Share on other sites More sharing options...
Boatswain2PA Posted April 19, 2013 Author Share Posted April 19, 2013 no one in vfib is talking. do you mean afib with rapid ventricular response? Yes. I guess the point if this part of his presentation was that WPW in A-fib w/rvr can go so fast that it can LOOK like V-fib (fast, wide, &irregular), yet they are still talking to you so they CAN'T actually be in V-Fib, so treat them like they are in wide complex V-tach (Amiodarone). Link to comment Share on other sites More sharing options...
Just Steve Posted April 19, 2013 Share Posted April 19, 2013 "Control of ventricular rate in atrial fibrillation: pharmacological therapy" in UpToDate! places amioderone as a class2c intervention, after CCB's and beta blockers. "pharmacological therapy of arrythmias associated with Wolff Parkinson White" in UpToDate also supports CCB for acute management and does not speak favorably of amio for this purpose. The article goes so far to say Amio is not approved in the US for this purpose. They place it's off label consideration behind electrical cardio version. Speaking from literature review, lectures, and actually using the drug on patients several times for a variety of cardiac issues, it's efficacy is moderate at best, the side effects suck, and the drug has one of the longest half lives out there for cardiac care. If a patient presents to the ER for their WPW, they are probably symptomatic with a crappy pressure and feel awful. Their stroke volume is in the toilet and their MAP is so weak it can't perfuse the kidneys, thus pushing them towards acute renal failure. Symptomatic dyshythmias buy a dose of electricity. After all, the loading dose of 150 mg Amio dripped over ten minutes is a long time when you are looking at a pressure if 70/systolic The chance of them staying converted for the long term > 4-5 months is low so they do need long term rhythm or rate control and PO amio can be used. However, that can be addressed by their PCP/Cards consult, doesn't need to happen in the ER. I would consider starting warfarin therapy until they can further discuss it with Cards or PCP to reduce risk of emboli. People don't typically suffer morbidity/mortality from rate controlled atrial fib, it is the stroke from emboli (potentially) that we worry about. Historically a-fib is converted/ablated so he patient feels better and doesn't have to take a potentially dangerous drug for the rest of their life. Drug companies are pushing newer generation oral anti thrombolics such as dabagatran and rivaroxaban that have no antagonist like Vit K for warfarin. This may prove to be not so great in fall prone elderly. So ER setting, symptomatic afib with rvr/wpw that doesn't respond to CCBs (or has a pressure that sucks and wont support ccb) and continues to spiral downhill buys electricity. If you decide to sedate prior to cardio version, etomidate is a lot more cardiac neutral than propophol or midazolam and will hopefully preserve what little blood pressure you have left. So goes the opinion (based on education, literature, practical experience) of just a lowly green PA student. Link to comment Share on other sites More sharing options...
Just Steve Posted April 19, 2013 Share Posted April 19, 2013 "Control of ventricular rate in atrial fibrillation: pharmacological therapy" in UpToDate! places amioderone as a class2c intervention, after CCB's and beta blockers. "pharmacological therapy of arrythmias associated with Wolff Parkinson White" in UpToDate also supports CCB for acute management and does not speak favorably of amio for this purpose. The article goes so far to say Amio is not approved in the US for this purpose. They place it's off label consideration behind electrical cardio version. Speaking from literature review, lectures, and actually using the drug on patients several times for a variety of cardiac issues, it's efficacy is moderate at best, the side effects suck, and the drug has one of the longest half lives out there for cardiac care. If a patient presents to the ER for their WPW, they are probably symptomatic with a crappy pressure and feel awful. Their stroke volume is in the toilet and their MAP is so weak it can't perfuse the kidneys, thus pushing them towards acute renal failure. Symptomatic dyshythmias buy a dose of electricity. After all, the loading dose of 150 mg Amio dripped over ten minutes is a long time when you are looking at a pressure if 70/systolic The chance of them staying converted for the long term > 4-5 months is low so they do need long term rhythm or rate control and PO amio can be used. However, that can be addressed by their PCP/Cards consult, doesn't need to happen in the ER. I would consider starting warfarin therapy until they can further discuss it with Cards or PCP to reduce risk of emboli. People don't typically suffer morbidity/mortality from rate controlled atrial fib, it is the stroke from emboli (potentially) that we worry about. Historically a-fib is converted/ablated so he patient feels better and doesn't have to take a potentially dangerous drug for the rest of their life. Drug companies are pushing newer generation oral anti thrombolics such as dabagatran and rivaroxaban that have no antagonist like Vit K for warfarin. This may prove to be not so great in fall prone elderly. So ER setting, symptomatic afib with rvr/wpw that doesn't respond to CCBs (or has a pressure that sucks and wont support ccb) and continues to spiral downhill buys electricity. If you decide to sedate prior to cardio version, etomidate is a lot more cardiac neutral than propophol or midazolam and will hopefully preserve what little blood pressure you have left. So goes the opinion (based on education, literature, practical experience) of just a lowly green PA student. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 19, 2013 Moderator Share Posted April 19, 2013 [quote name=Just Steve;387341 So goes the opinion (based on education' date=' literature, practical experience) of just a lowly green PA student.[/quote] who also happens to be a medic and navy corpsman for over 20 yrs...don't sell yourself short....and for what it's worth, I agree with your summary. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted April 19, 2013 Moderator Share Posted April 19, 2013 [quote name=Just Steve;387341 So goes the opinion (based on education' date=' literature, practical experience) of just a lowly green PA student.[/quote] who also happens to be a medic and navy corpsman for over 20 yrs...don't sell yourself short....and for what it's worth, I agree with your summary. Link to comment Share on other sites More sharing options...
marvi1kd Posted April 19, 2013 Share Posted April 19, 2013 Amal Mattu is my favorite! Here is a video that sums up the issue very nicely and is worth a watch. You guys are awesome!!! http://ekgumem.tumblr.com/page/8 (WPW w/AFib) What I got out of it: 1.) AV Nodal Blockers = bad 2.) Amiodarone = bad (part Class II and IV) 3.) Procainamide = :) 4.) Shock em' = :) I apologize for posting in the professional section, but I love electrocardiography so I just had to :) Link to comment Share on other sites More sharing options...
marvi1kd Posted April 19, 2013 Share Posted April 19, 2013 Amal Mattu is my favorite! Here is a video that sums up the issue very nicely and is worth a watch. You guys are awesome!!! http://ekgumem.tumblr.com/page/8 (WPW w/AFib) What I got out of it: 1.) AV Nodal Blockers = bad 2.) Amiodarone = bad (part Class II and IV) 3.) Procainamide = :) 4.) Shock em' = :) I apologize for posting in the professional section, but I love electrocardiography so I just had to :) Link to comment Share on other sites More sharing options...
Boatswain2PA Posted April 20, 2013 Author Share Posted April 20, 2013 So goes the opinion (based on education, literature, practical experience) of just a lowly green PA student. Thank you ya old salt Link to comment Share on other sites More sharing options...
Boatswain2PA Posted April 20, 2013 Author Share Posted April 20, 2013 So goes the opinion (based on education, literature, practical experience) of just a lowly green PA student. Thank you ya old salt Link to comment Share on other sites More sharing options...
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