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In a sick patient with chronic atrial fibrillation and rapid rate, think of the tachycardia like you would sinus tach. Leave it alone and look for the underlying cause.
I love it when a study comes out that supports your practice. I've had several septic patients come in over the years in a fib with RVR who I just gave fluids to and they gradually slowed from 130 or 140 down to about 100. I also had a patient with sudden CP, SOB, palpitations and a swollen leg in AFib at 150, that I was a little nervous to rate control, because I was pretty sure it was a PE. A couple of RNs were uncomfortable with my decision to delay rate control/cardioversion, and just give some fluids to help preload, but I felt like he needed the rate to maintain cardiac output. Glad to see some justification for this approach.
So I think we have all had this patient at sometime. Other day I had a person with CC of chest pain was in Afib with rVr 150s with a pressure of 86/53. As I walk in I instantly smell smell melena. He responded quite well to fluids and got FFP For an elevated INR. I will say though there is a major weakness in this chart review... The complex patients are always going to have high complications, intuitions, CPR etc because they also have serious illness. this is a huge confounder between these two groups. We just to remember to do what we think is right for the patient with the information we have.
I think the frequently forgotten agent in rate control for a-fib is starting a digoxin load. It is certainly is less effective than BB or CCBs but especially in the "Complex" a-fib patient it may augment medical resus, while having a less detrimental effect for the patient with another ongoing medical issue. My feeling it that it allows you to do something for rate control without the downside of more the aggressive strategies,
What you do matters.