Rapid atrial fibrillation, rvr

[SanDiegoEmt7]

I had a patient tonight from a rehab facility. Male, mid 50's, been rehabbing for one week status post cva (only deficit dysphasia). Per staff patient has had a fever of 38.0 for the last 5 hours and they also noted a fast heart rate of ~170. They said their 12 lead machine was out of service, so they used the monitor on their crash cart which did indeed confirm a rapid heart rate. They gave him tylenol and when that had not corrected is heart rate two hours later they called us out.

Rapid A fib on the monitor, increased drowsiness and dysphasia per wife at bed side (how good of a baseline they have on this patient is hard to say). No cardiac history, no history of a fib.

After giving hand over at the hospital the doctor states he feels the fever is the culprit. Can anyone shed light on this?

 

[usafmedic45]

Lots of stuff can induce A-fib....pretty much anything that will irritate the atria. Alcohol is well known for it ("holiday heart syndrome"). I've seen it a few times in patients who are running high fevers. Normally in these cases, once the underlying issue is removed, the atrial fib will correct itself.

 

[KellyBracket]

Sounds like the patient needed to have their AF treated with a couple liters of saline, and antibiotics.

 

[IrightI]

Fever is a culprit for tachycardia. You mentioned a-fib so, i would guess that he had a hx of a-fib, but you recieved a poor report from the nursing staff at the snf(what a surprise there!!) At 170bpm, treat the fever, hang a bag and a drip of Cardizem, see if that converts him, if it does he will be discharged home with a nice new cardizem script and an added hx of a-fib.

 

[KellyBracket]

Perhaps I was being glib, and I apologize. A fuller explanation of my proposed treatment plan would involve a few liter of NS to see if the heart rate or pressure would be affected. This is important, since a decreasing HR after 1 liter suggests that the tachycardia was an appropriate response to the systemic insult, the infection, and the limited ability to respond, namely hypovolemia (relative or absolute). In which case, it would be advisable to avoid treating the compensatory tachycardia.

Forget Tylenol - a nursing home patient with a fever and tachycardia (Health care-associated pneumonia?) need cefepime or the like!

 

[Smash]

Fever is a culprit for tachycardia. You mentioned a-fib so, i would guess that he had a hx of a-fib, but you recieved a poor report from the nursing staff at the snf(what a surprise there!!) At 170bpm, treat the fever, hang a bag and a drip of Cardizem, see if that converts him, if it does he will be discharged home with a nice new cardizem script and an added hx of a-fib.

Hang a bag of what? How would you treat the fever? More importantly, why would you treat the fever? In the setting of a patient with presumed sepsis do you think that causing decreased cardiac output and increased vasodilation with a calcium channel blocker will be a good or bad thing?

 

[SanDiegoEmt7]

I guess what threw me off was the family adamantly denying any cardiac history or atrial fibrillation, confirmed by the staff who were supposedly monitoring vitals throughout his stay and denied any previous irregular rhythm.

Given that I take everything from rehab staff with a block of salt.

So minus the fact that I missed the boat on differentials, what would your course of treatment be. I see a few votes for fluids, calcium channel blockers would be out of the question for us since this patient didn't have chest pain, hypotension, poor perfusion, etc. He was simply more altered with rapid afib and rvr.

EDIT: Prehospital treatment

 

[usafmedic45]

Don't kick yourself and never rule something out simply because the patient denies a history of whatever. The sage advice about "trust but verify" is very good when applied to the medical field. The other points to keep in mind are that just because there's a cardiac sign does not mean it's a primary cardiac problem. This is something that EMS providers tend to be very poor in with regards to our training. If you ever want to get a blank stare from a group of EMS providers, ask them to name the three major organ or organ systems that most significantly affect acid-base balance (kidneys, lungs and gastrointestinal tract) and to explain how each plays a role.

Any other basic aspect of physiology can be substituted but the point remains the same: we are taught too much a system-based manner of thinking which hinders a large percentage of our ranks when presented with a complex or confounding set of problems. As soon as we get away from something easily managed by linear thought processes, the blank stares develop and panic starts to set in.

 

[mycrofft]

Tylenol to slow afib, a facility without a 12 lead using the crash cart monitor?

Snakebit run. SNF's used to dump pt's on us so they would die in our ambulance instead of their facility when they were as clued-out as this one was.

Could the fever be due to a hypothalamic-related CVA? But that would be the hospital's part of the patrol.

The a-fib will be there waiting for a trigger, such as getting another year older, stress, or that second can of Mt Dew. Trust me.

The linear process, thanks, that's the concept I've been trying to name for the last three years. That is what make us think we can solve everything through a cookbook, and 80% can, but Pareto's 20% will need concatenary thinking. Or create AI by linking more and more memory into more and more computers.