In the ED, their vitals/exam are as above. Patient with irregular narrow complex tachycardia on monitor/EKG suggestive of AFib vs. AFlutter (more likely AFib given ventricular rate is not 150 and there is no sawtooth pattern). *** history of accessory pathway necessitating avoidance of AV blocking agents and preference for procainamide/amiodarione. No evidence of >3 p-wave morphologies to suggest MAT requiring search for underlying lung disease. Unclear underlying etiology of patients acute on chronic irregular narrow complex tachycardia. 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 incredibly unlikely patient is having ACS, will give an idea as to the patient’s level of demand), BNP, TSH, 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), IV calcium gluconate 2g if using diltiazem (to prevent hypotension), Rate control <110 with diltiazem (10mg IV -> 20mg IV -> 30mg IV q15 mins + chase with 30mg PO) 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), Synchronized cardioversion if unstable (hypotension, AMS, chest pain, pulmonary edema), Use phenylephrine if pressor needed given reflex bradycardia, Continue anticoagulation
– Consults: None, but low threshold consult cardiology/EP
– Dispo: Likely admission to medicine vs. Cardiology
