Hx
- Hx of a fib
- Denies feeling of palpitations.
- Denies chest pain
- Denies shortness of breath
- Denies any recent stimulants, caffeine, illicit medications.
- States is admherent to rate control medications.
- On anticoagulation
MDM:
- Suspect atrial fibrillation with RVR.
- Stability:
- Upon arrival in the emergency department, patient was evaluated for stability.
- Patient is stable by virtue of:
- Sufficient blood pressure,
- Normal mentation/no encephalopathy
- No chest pain thought to be secondary to ischemia
- No shortness of breath
- ED Course:
- Upon arrival in the emergency department, an EKG was obtained emergently. EKG, as described above revealed atrial tachycardia with rapid ventricular response.
-
- Given patient is stable with atrial fibrillation with tachycardia will elect for pharmacologic rate control.
- Diagnostically:
- CBC to evaluate for significant anemia
- BMP to evaluate for electrolyte derangements
- Magnesium and phosphorus
- Chest x-ray
- Therapeutically:
-
- diltiazem 20 mg IV under my direct observation.
- Subsequent to that patient had continued atrial tachycardia dose refractory to initial management.
- dilatiazem 20mg IV (2nd dose)
- To prevent recurrence of RVR,
- Diltiazem drip at 5 mg per hour initiated emergently with titration goals of heart rates to 110s with hold parameters for hypotension.
- Diltiazem 60mg PO given.
- Evaluated for precipitant of atrial fibrillation with RVR:
- Unlikely medication noncompliance given patient states he is compliant with his medications for rate control.
- Unlikely electrolyte derangements given electrolytes evaluated which were nonremarkable.
- Unlikely infectious precipitant given on review of systems and examination, there is no obvious infectious cause.
- Unlikely ischemic event precipitant given history not typical for myocardial ischemia and negative troponin.