Day #139 - Atrial Fibrillation

Today we talked about a case of rapid atrial fibrillation.

The ACC guidelines for atrial fibrillation are here, and the ACLS tachycardia algorithm is here.

Is the AF causing severe CHF, hypotension or angina? If so manage as unstable. Otherwise manage as stable.

Unstable:

• DC Cardioversion

Stable:

• Does the patient have pre-excitation or a grade III/IV LV?
  
  • Amiodarone 150mg IV over 10 minutes, can repeat, then give 360mg IV over 6h then 540mg IV over 18h loading. Risk of cardioversion.
• No WPW or grade III/IV LV:
  
  • IV beta blocker (like metoprolol 5mg IV over 2 mins, can repeat q 5 mins x 3)
  • IV calcium channel blocker (diltiazem 0.25mg/kg IV over 2 mins, can repeat in 10 mins with 0.35mg/kg IV)
  • Follow up with oral agent of same class
• There is evidence that IV magnesium can be effective as a rate control agent, either alone or in combination.
  
• Afib of less than 48h duration (or no thrombus on TEE) can consider cardioversion either electrical or chemical.
• Does this patient need anticoagulation?
  
  • CHADS2 score if greater than or equal to 2, yes. Otherwise anti-platelet agents.
    

Consider the cause of the AF:

• Hypertension
• Structural Heart Disease
• Hyper/hypo thyroidism
• Alcohol/Stimulants
• Ischemia
• PE
• Infection
• Other stressor

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We have previously talked about septic bursitis and septic arthritis here.

I will expand on that by saying that one of the keys in effective management is source control. The septic joint should be repeatedly tapped until there is a negative culture and the cell count is dramatically decreased. If it isn't improving -- they will need surgical management. If you can't tap the joint, they will need surgical management. This is particularly a problem with "difficult" to aspirate joints like the shoulder or hip. These patients should have orthopedic surgery to wash out the joint.

Failure to drain the joint can lead to treatment failure and joint damage.

Here is a good review of the diagnosis and management of acute septic arthritis.

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1. For the record, ciprofloxacin monotherapy is a totally inappropriate empiric choice for the treatment of community acquired cellulitis (even if the patient is penicillin allergic)
   
   • Penicillin allergy is one of the bains of my existance. I direct you to this article on trying to determine if a history of penicillin allergy is "real".