In the ED, their vitals/exam are as above. Given narrow complex tachycardia with ventricular rate near 150 and sawtooth pattern on monitor/EKG, patient’s presentation is suggestive of atrial flutter {Blank single:19197:: “with variable block (given irregular)”,”without variable block (given regular)”}. With*** history of accessory pathway necessitating avoidance of AV blocking agents and preference for procainamide.
Unclear underlying etiology of patient’s atrial flutter. Differential includes volume overload, hypovolemia, electrolyte abnormality, infection, ACS, CAD, valvular disease, myo/pericarditis, endocarditis, DVT/PE hyperthyroidism, anemia, surgery, OSA, COPD, alcohol, caffeine, cocaine, theophylline, adenosine, digitalis, exercise, and emotion. With*** evidence of DVT/PE at this time including without pleuritic chest pain, unilateral swelling of legs so no d-dimer indicated. No signs and symptoms of focal weakness concerning for embolic stroke. CHADS2VASC *** (>/ 2 = needs anticoagulation). HASBLED *** (>/ 3 = use caution).
– Labs/Tests: CBC, CMP, lipase, coags, troponins (although unlikely patient is having ACS, will give an idea as to the patient’s level of demand), BNP, TSH with reflex FT4, UA w/ reflex UCx, ***
– Imaging: CXR, BSUS including IVC to assess fluid status, TTE as inpatient
– Treatments:
— IVF vs. diuresis based on fluid status
— IV magnesium 4g (works as CCB)
— Rate control <110 with diltiazem (10mg IV -> 20mg IV -> 30mg IV q15 mins + chase with 30-60mg PO +/- IV calcium gluconate 2g if using diltiazem to prevent hypotension) vs. metoprolol (5mg IV q5mins up to total of 15mg + chase with 25mg PO) as indicated
—- Consider amiodarone if patient’s AF does not relent/hypotensive/in ADHF
—- Consider IV procainamide (15mg/kg OR 100mg bolus q5mins until arrhythmia controlled; 1g max -> 1-4mg/min gtt) if history if accessory pathway
— Anticoagulation (Eliquis 5mg BID vs. LMWH vs. Heparin) if indicated per CHADS2
— Synchronized cardioversion if unstable (hypotension, AMS, chest pain, pulmonary edema)
— Use phenylephrine if pressor needed given reflex bradycardia
– Consults: None, but low threshold consult cardiology/EP
– Dispo: Pending clinical resolution
