***AFIB

Paroxysmal aFIB (new onset) presents with new onset paroxysmal aFIB, intermittently symptomatic with SOB. Likely symptomatic when in aFIB w RVR. No known underlying etiology, no h/o HF, CVA, hyperthyroidism; no symptoms of infection, unlikely MI. Plan basic labs and assess for infection with UA, CXR, and blood cultures as well as cardiac markers (Trop and BNP), and TSH. Uncertain historical reliability with time of onset; will defer cardioversion. EKG: ___ CHADS VASC score: ___ Reassessment: Pt maintained NSR during multi-hour observation in ED. Plan DC home with prompt PCP follow up and cardiology referral. 

aFIB w RVR No h/o HF. Otherwise been in normal state of health at home with no infectious symptoms. Unlikely PTX, PNA, PE, tamponade, MI, thyrotoxicosis. Workup: 12lead ECG. CXR. CBC, BMP, Mg2+, Phosphorus, Troponin, BNP, CXR, PT/INR, PTT. Suspect troponin may be indeterminate 2/2 demand ischemia. ECG ___ not representative of WPW. 

  • Initial treatment: 
  • Diltiazem 15mg IV bolus over 2min followed by 25mg 
  • OR Metoprolol 5mg IVP over 2min q5min up to 3 doses
  • If patient responds 
  • to Diltiazem: –> infusion at 5-15mg/hr OR PO Diltiazem 60mg QID 
  • to Metoprolol: –> oral load with 25-50mg
  • aFIB w RVR + Acute Decompensated CHF with pertinent PMH CHF and aFIB presents in aFIB with RVR to the ED w concomitant SOB c/f acute decompensated HF. Pt has been afebrile with no productive cough. No exogenous estrogen, no recent travel or operations, no CA history, ambulatory at home. Unlikely PTX, PNA, PE, tamponade, MI, thyrotoxicosis. Workup: Plan recurrent 12lead ECG. CBC, BMP, Mg2+, Phosphorus, Trop, BNP, CXR, coags. Suspect trop may be indeterminate 2/2 demand ischemia. ECG ___ not representative of WPW. 
  • If MILD HF: 
  • Initial treatment with low dose 10mg Diltiazem IV and 40 Lasix IV (double home dose). 
  • Plan change to oral load of 30 PO q6 Diltiazem if responsive to near 110BPM
  • If Moderate to Severe HF: Initial treatment with Anti-dysrhythmics (that also treat the CHF), avoid B-blockers and Ca2+ blockers 
  • Initial treatment with Amiodarone 150mg IV bolus over 30 min, then 1mg /min 6 hr 
  • Onset minutes to hour after loading dose IV
  • Digoxin 0.25mg IV q2hr 
  • ~2 hours
  • ***BRADYCARDIA
  • The patient is suffering from bradycardia, but the immediate cause is not apparent. Patient without concerning signs of instability on exam such as altered mental status, hypotension, evidence of cardiac end organ dysfunction, or acute heart failure. Potential emergent causes considered include, but are not limited to, myocardial infarction (RCA lesion), infection, hypothyroidism, hyperkalemia, hypoglycemia, dehydration, anemia, or intoxication (beta blockade, calcium channel blockade, clonidine, digoxin, opiates, alcohol or other).

    ED Workup: 
  • CBC, BMP, LFT, TSH, lactate, UA, UDS, CXR, ECG
  • ED interventions:
    ***

  • ED Findings: 
  • Despite the evaluation including history, exam, and testing, the cause of the bradycardia remains unclear. However the history, exam, and tests do not raise concern for the above emergent diagnoses.

    Plan: 
  • ***
  • ***SVT
  • presents with palpitations and ECG is noted to be indicative of supraventricular tachycardia.
    Initial ECG:
  • Palpitations unlikely secondary to other concomitant cause such as pulmonary embolus or ACS.
  • ED Interventions:
    Patient did not respond to vagal syringe blow + modified vagal lay back.
    The patient’s vital signs and clinical condition warranted the use chemical cardioversion and given their rhythm adenosine was chosen.
    A time out was undertaken to assure that this was the correct patient and the correct procedure for this patient.
    Adenosine 6___ mg was given in the standard rapid IV push fashion.
    The result of this chemical cardioversion was a return to a normal sinus rhythm.
    The patient tolerated this procedure very well, there were no complications.
  • Post Conversion ECG: Without overt e/o STEMI, Brugada’s sign, delta wave, epsilon wave, significantly prolonged QTc, or malignant arrhythmia.
  • Plan:
    Counseled patient to avoid stimulants.
    This is not patients first SVT. They are __ taking B blocker therapy at home.
    Counseled patient to follow up within 24-48 hours with their cardiologist and primary care doctors.
    Discharge home with SRP.
  • ***TACHYCARDIA
  • The patient is suffering from tachycardia, but the immediate cause is not apparent.
  • Potential causes considered include, but are not limited to, infection, hyperthyroidism, pulmonary embolism, pericarditis, dehydration, anemia, pheochromocytoma, drug/alcohol withdrawal or intoxication.
  • ED Workup: CBC, BMP, LFT, TSH, lactate, UA, UDS, CXR, ECG, d-dimer
  • ED interventions: 3L 0.9% NS IVF
  • Despite the evaluation including history, exam, and testing, the cause of the tachycardia remains unclear. However the history, exam, and tests do not raise concern for the above emergent diagnoses.
  • Disposition: During the ED stay, patient’s tachycardia improved, and at the time of discharge they are feeling well and want to go home.
  • ***TORSADES
    Patient with recurrent near syncopal symptoms. Patient currently stable with ECG demonstrating evidence of significant QT prolongation with transient episode of Torsades captured on monitor.
  • Pertinent Negatives: No recent new ABX, antiemetic, antipsychotic, TCA or other antidepressant use. No family history of sudden cardiac death and no h/o deafness. No known h/o congenital long QT or catecholaminergic PMVT. Pt otherwise in normal state of health, normotensive at triage. No head trauma.
  • Less likely DDx: Doubt ICH. Low suspicion at this time for ACS, dissection. Unlikely GI bleed.
  • Workup: Will check CBC + BMP and Ca-Mg-P for electrolyte disturbances. Will obtain troponin, repeat ECG and reassess.
  • ED interventions: Magnesium 2 grams IV (over 10-20 minutes) followed by 1-4 grams/hr, potassium and calcium repletion, Isoproterenol: Start at 5mcg/min
  • Disposition: Plan CCU admission for continued cardiac monitoring and evaluation to prevent recurrence.
  • ***STEMI
  • EKG:  NSR with a rate of ***, normal axis, normal conduction, with ST and T waves showing ***.  
  • Impression: *** ST Elevation Myocardial Infarction.  
  • Timing of events:  
  • ***  Initial EKG
  • ***  EKG seen by attending physician
  • ***  STEMI Alert called
  • ***  Cardiologist paged
  • ***  Cardiologist returned call
  • ***  Patient to Cath Lab
  • OLD RECORDS REVIEWED:
  • Previous ECG: {Time; dates multiple:15870} reviewed and demonstrates {Blank single:19197::”no changes”, “ischemic changes”, “non-specific changes”,”***”}
  • Old Cath: {Time; dates multiple:15870} reviewed and revealed {Blank single:19197::”that no interventions were performed”, “minimal disease without progression”, “significant disease with the need for intervention”,”***”}
  • Old ECHO: {Time; dates multiple:15870} reviewed and was found to be {Blank single:19197::”concerning for worsening disease”, “concerning for new disease”, “insignificant for progressive disease”,”***”}