Mystery Case #3

that was extraordinary.

question Sara.
so the HR went to 200after 500cc fluid bolus because of diastolic dysfunction? (ie, was stressed by the fluid?).
your plan of action may have been phenylephrine, then amiodurone, maybe magnesium , precedex and cardiovert?

thank you both, truly.

tom fiero, merced, ca

Just re-listened to this pod. It addresses a great deal of fine points , quite intricate; it is truly info packed. this case was actually quite complicated, but an excellent teaching vehicle.

Hi Tom, so the thought Sara had is that because of the diastolic dysfunction that she likely had (and it's a safe bet that most older patients have some amount of diastolic dysfunction) she couldn't handle fluids (can't relax the muscle and absorb the volume), so things backed up, stretched her atrium, and made the a fib got worse. And yes, that's essentially what Sara's plan was though she really did bang me over the head about optimizing the K and mag (4.5/2.5) as a first step and before/while giving amio.

It definitely changed how I consider and manage trying to get people out of a fib and I've seen almost this exact situation since. A few weeks ago I was cautioning a resident about giving fluids to a sick patient in new a fib with soft pressures who was definitely septic, and then almost the exact same thing happened after "gentle fluids."

I hope that helps.

best
jake