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Atrial flutter

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 AFlutter given ventricular rate is 150 and there is a sawtooth pattern). No evidence of >3 p-wave morphologies to suggest MAT requiring search for underlying lung disease. Unclear underlying etiology of patients new onset 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, coags, troponins (although incredibly unlikely patient is having ACS, will give an idea as to the patient’s level of demand), BNP, TSH, UA, ***
– Imaging: CXR, BSUS including IVC to assess fluid status, TTE as inpatient
– Treatments: IVF vs. diuresis based on fluid status, Rate control <110 with dilt (10mg IV -> 20mg IV -> 30mg IV + chase with 30mg PO) vs. metoprolol (5mg IV q5mins up to total of 15mg) as indicated (consider amiodarone if patient’s AF does not relent), IV magnesium, IV calcium gluconate as indicated, 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
– Dispo: Likely admission to medicine vs. cardiology

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