EKG Case

Case:
70 y.o female with past medical history of hypothyroidism and COPD, presenting with chief complaint of “heart racing”. Symptoms began earlier that day. Patient denies any chest pain or shortness of breath.

Initial Vital Signs: HR 112, BP 112/74, RR 18, O2 Sat 100%

Exam: Remarkable only for tachycardia and irregular rhythm

Picture1.png
 
 

1. What is your impression of the EKG?

Let’s break it down……

  • Rate ~140- 150

  • Rhythm – Irregularly irregular

  • Conduction Intervals: PR – do you see any P waves?, QTc – normal ~ 400ms

  • Anything Else? (i.e ST elevation/depression, T wave abnormalities, RS abnormalities)- No!

2. What does this EKG finding suggest?

Atrial Fibrillation with rapid ventricular rate Key features of A fib:

  1. Irregularly irregular rhythm

  2. No P waves

  3. Irregular “fibrillatory” waves – best seen in V1

3. Why is this important?

Atrial Fibrillation increases your risk of thrombus formation and of embolic stroke!

Key features of A fib:

  1. Irregularly irregular rhythm

  2. No P waves

  3. Irregular “fibrillatory” waves – best seen in V1

Why is this important?

Atrial Fibrillation increases your risk of thrombus formation and of embolic stroke!

What should be your next step of management?

Is the patient Stable or Unstable?

Unstable = Cardioversion!

Stable?

o Diltiazem: dose = 0.25 mg/kg IV over 2 min followed by a 2nd bolus of 0.35mg/kg IV over 2 min

o OR 5mg slow push (max of 50mg) followed by a drip 5-15mg/hr

o Metoprolol: dose 5mg IV Q5min up to 15mg

Recent prospective randomized double blinded study by Fromm C et al comparing diltiazem vs metoprolol in decreasing HR <100 data-preserve-html-node="true" in w/in 30 min showed diltiazem had a more rapid rate control

Other drugs

o Esmolol: dose = 0.5mg/kg bolus over 1 min, followed by a drip 0.05-0.2mg/kg/min

o Digoxin: loading dose of 0.5mg then repeat

o Amiodarone: dose = 150mg IV over 10 min followed by drip

What is your impression of the EKG?

Let’s break it down……

-       Rate ~140- 150

-       Rhythm – Irregularly irregular

-       Conduction Intervals: PR – do you see any P waves?, QTc – normal ~ 400ms

-       Anything Else? (i.e ST elevation/depression, T wave abnormalities, RS abnormalities)- No!

 

What does this EKG finding suggest?

Atrial Fibrillation with rapid ventricular rate

 

Key features of A fib:

1.     Irregularly irregular rhythm

2.     No P waves

3.     Irregular “fibrillatory” waves – best seen in V1

 

Why is this important?

Atrial Fibrillation increases your risk of thrombus formation and of embolic stroke!

 

What should be your next step of management?

Is the patient Stable or Unstable?

Unstable = Cardioversion!

Stable?

o   Diltiazem: dose = 0.25 mg/kg IV over 2 min followed by a 2nd bolus of 0.35mg/kg IV over 2 min

o   OR 5mg slow push (max of 50mg) followed by a drip 5-15mg/hr

o   Metoprolol: dose 5mg IV Q5min up to 15mg

Recent prospective randomized double blinded study by Fromm C et al comparing diltiazem vs metoprolol in decreasing HR <100 in w/in 30 min showed diltiazem had a more rapid rate control

Other drugs

o   Esmolol: dose = 0.5mg/kg bolus over 1 min, followed by a drip 0.05-0.2mg/kg/min

o   Digoxin: loading dose of 0.5mg then repeat 

o   Amiodarone: dose = 150mg IV over 10 min followed by drip

 

Additional Resources:

EMCrit: http://emcrit.org/emnerd/the-case-of-the-irregular-irregularity/

o   Tips on what to do when cardioversion doesn’t workhttp://emcrit.org/podcasts/crashing-a-fib/

Life in the Fast Lane: http://lifeinthefastlane.com/ecg-library/atrial-fibrillation/

EBM Medicine: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=53

Rebel EM: http://rebelem.com/journal-update-beta-blocker-vs-calcium-channel-blocker-for-rate-control-in-atrial-fibrillation/

Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. http://www.ncbi.nlm.nih.gov/pubmed/25913166