January 18, 2016
Atrial Fibrillation and Flutter, Disposition: Many patients with atrial fibrillation/flutter that receive rate control or rhythm conversion in the emergency department do not need hospital admission and can be safely discharged from the ED with follow-up arranged. While there is significant institutional and regional variation in disposition practices, we have provided a summary of reasonable practice indicating criteria for discharge and admission and options for outpatient anticoagulation.
INITIAL APPROACH TO THE STABLE PATIENT
The focused evaluation of the patient includes determining the presenting complaint(s), obtaining the medical history, identifying medication use, performing a physical examination, initiating continuous cardiac rhythm monitoring, reviewing the 12-lead ECG, and analyzing the cardiac rhythm on the rhythm monitor, a printer strip, or the ECG.
Presenting symptoms may include palpitations, lightheadedness, fatigue, or weakness. Ischemic symptoms, such as chest pain, nausea, dyspnea, or lightheadedness, may be due to dysrhythmia-induced ischemia.
The medication history includes prescribed medications, herbals, recreational drugs, and caffeine-containing beverages. Especially note recently started new medications or increased medication doses. Symptoms of hyperthyroidism should be sought. Patients with a family history of sudden death, syncope, or dysrhythmias and those with organic heart disease have a higher risk of cardiac dysrhythmias and complications. Panic or anxiety is a diagnosis of exclusion in tachycardic ED patients.
INITIAL APPROACH TO THE UNSTABLE PATIENT
An unstable patient needs rapid assessment and treatment to prevent cardiovascular collapse. Instability means that the dysrhythmia is (1) impairing cardiac output and threatening vital organ function or (2) has the potential to suddenly deteriorate into cardiac arrest (Table 18-1).1 Establish an IV line, initiate cardiac rhythm monitoring, obtain an ECG, and be prepared for drug or electrical therapy.
Table 18–1Instability Indicators in the Patient with Cardiac Dysrhythmias |Favorite Table|Download (.pdf) Table 18–1 Instability Indicators in the Patient with Cardiac Dysrhythmias
|Hypotension: e.g., systolic blood pressure <90 mm Hg (<12 kPa) |
|Systemic hypoperfusion |
|Altered mentation |
|Ischemic chest pain |
|Respiratory distress |
|Extremely rapid ventricular rate: e.g., rate over 200 beats/min in adult |
Dysrhythmia-induced chest pain results from coronary hypoperfusion, and dyspnea results from pulmonary edema, usually with objective evidence: ST segment abnormalities, rales on examination, or low oxygen saturation. As the ventricular rate exceeds 200 beats/min, severe systemic hypoperfusion often results and the RR interval narrows proportionally, increasing the opportunity for malignant ventricular dysrhythmias.
GENERAL APPROACH TO BRADYDYSRHYTHMIAS
Bradydysrhythmia describes rhythms with a ventricular rate slower than 60 beats/min in the adult. Age-appropriate heart rates define pediatric bradydysrhythmia. Bradydysrhythmias can be broadly categorized as bradycardias (atria and ventricles beat at the same slow rate) and atrioventricular (AV) blocks (ventricles beat slower than the atria).1 The bradycardias include sinus bradycardia, junctional rhythm, idioventricular rhythm, and ...