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Introduction - What Really Happens After Acute A-fib

Rob Orman, MD and Anand Swaminathan, MD FAAEM
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN

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EM:RAP 2017 May Written Summary 839 KB - PDF

Ian Stiell and the Canadian crew explore what really happens to patients after they present to the ED with recent onset atrial fibrillation.

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Ross B. -

This is a great segment on A Fib. However, I'm wondering about the description of pts who were sent home after rhythm control who were not anticoagulated. My understanding of the CHAD2 and CHAD2Vasc scores are that they calculate the risk of a clot in pts with chronic a fib; not those pts who, have paroxysmal a fib (or pts who have had a fib and now are cardioverted and in sinus rhythm). Can you comment on how to rationally approach those pts who have paroxysmal a fib or a fib that has now been restored to sinus rhythm and if these scores are applicable to them?

Rob O -

Hey Ross! The heterogeneity of a fib patients makes prognostication a challenge, but the conventional wisdom is that the stroke risk is similar in those with paroxysmal a fib and chronic a fib.

Anand S., M.D. -

Ross - I don't think we have great "rules" for helping manage the patients with paroxysmal AF or those that we convert. Many (maybe most) use CHADS and the like to help gauge risk. If I convert the patient and it's a first episode, I often just do 81 mg ASA and then schedule urgent follow up. If they've had recurrent episodes and they're > 1 on CHADSVASC, I go with AC. Definitely interested to see what others do


Dear Rob and Tim - As a EM/Peds EM specialist , I truly enjoy every-time a pediatric EM topic is brought to the forefront of the episode and hits 20000 ears! Truly awesome the topics on the little patients get big discussions...

I was just surprised that after discussing the Kocher criteria no one mentioned the major flaws of the kocher criteria studies (both derivation and so called validation). All Kocher studies had very high pretest probability of Septic Arthritis and their population was highly selected (i.e. only those patients referred to Orthopedics - not all comers to the ED).

Applying the Kocher would be like if we applied a C-spine rule that was derived in only 80 year old RA patients who happen to have severe spinal stenosis. Kocher was never tested in Steill et al/Ottawa rigor like our more modern decision instruments - so I'd have a healthy degree skepticism in using the rule in either direction.

In reality Septic Arthritis is still an infrequent diagnosis and I'd agree with Andy Sloas step wise approach, but also add on a CRP to the mix. Additionally, I'd encourage all practitioners to try and risk stratify based on age/demographic rather that Kocher alone. As a matter of fact, in my Pediatric Tertiary care institution I'd have a hard time convincing the Ortho team to take anyone to the OR with Kocher alone; but on the other hand if Kocher was all negative but we have an immuno-supressed kid with a severely tender/restricted joint, we'd probably be having a different discussion.

I'd also caution EM practitioners not to attempt hip taps in kids (Yes- even if you use Ketamine and POCUS), for the only reason that a single OR tap is often both diagnostic and therapeutic; rather than having two (1 in ED for Dx, then 1 in the OR for treatment).

my humble two cents,

Anand S., M.D. -

Max - thanks for your thoughts. We agree with you that Kocher is just a piece and can neither definitely rule in or out the diagnosis. We tried to express that as well as offer an alternative approach (Sloas'). appreciate your "humble two cents." Adds a ton to the conversation about the nuances of the diagnosis. Thanks again!

Wendy H. -

I work in the heart of the heroin epidemic, rural Ohio just outside of Dayton. I really disagree with the dosing recommendations for narcan the show recommended. I had 14 overdoses on my recent 12 hour shift. The most common dose I or EMS had to use was 2mg IN and 4mg IV for a total of 6mg or '3 doses' per patients. The most I had to use was 28mg IV (overall a few minutes) and then placed on a gtt of 15mg an hour (carfentenyl overdose). I agree you can fix their ventilation with intubation, but if I intubated all 14 of those patients, which I would have done if I used your dosing guidelines from the show, I would use all the ventilators in my hospital. In my experience, the people who wake up swinging are generally the chronic pain patients that get carried away with their home narcs. Those patients I do go slow. I would encourage people before they intubate patients, they go big with the narcan. I've had three cases from EMS where they gave 0.4mg then intubated the patient, I gave 2-6mg IV and extubated them. Intubation is not benign. Why obligate someone to an ICU stay when you could likely discharge them home with bigger doses of narcan???

Anand S., M.D. -

Wendy - here's the response from Jeff LaPoint:
Thanks for your comment Wendy and for the opportunity to clarify a few points. Naloxone is a valuable tool and its judicious use is key to the practice Emergency Medicine. The key is to dose to ventilatory status rather than mental status, start low and titrate up, avoid unnecessary intubation when possible, and stay away from iatrogenic opioid withdrawal.

Jonathan S. -

I'm going to support Wendy on this one. While I was taught the approach in your podcast as s resident. The unknown polypharmacy or serum dose of Fentanyl or Carfentanil in a patient's system changes the game. The podcast made it sound as if after a slow creep to 1mg of Nalaxone you should stop and search somewhere else seems unsound in this new era. While putting someone into unnecessary withdrawal is a compassionate goal, it is a nicety not a priority for me. I will give upwards of 10mg of naloxone if I think this is the cause and I want my patient to wake up enough to assure myself there is no other concomitant disease process like a subdural or other emergent medical cause to address. Just getting someone to be safe ventilatory status is in my opinion not enough when your dealing with a black box patient in the ED, at least for the initial evaluation. Maybe for the Naloxone drip. This would also be supported by the recent increase in the dosing for community use from .4mg per injection to 2mg per injection agreed upon by the experts and by recent published reports of street pills with upwards of 6000mcg of Fentanyl in them.

Po H. -

A comment on the atrial fib approach in Canada. Since the publication of the the AFFIRM and RACE 2 trial the goal for a. fib treatment has been lenient heart rate control not rhythm conversion since it is better tolerated then antiarrythmic medications.

The problem I have with cardioversion is that symptom relief can also be achieved with diltiazem bolus followed by PO cardizem.

I guess if the symptoms are severe and the patient is young with known onset less 48 hours then cardioversion is an option. What then happens when they go home and go back into a fib?

Anand S., M.D. -

Po - thanks for the comments. As we discussed, this is a very controversial topic in EM, at least in the US. In other parts of the world, not as much.
AFFIRM mainly looked at patients with chronic AF (although not all of the patients were in that category). I agree that converting chronic AF doesn't make a whole lot of sense. Ablation? Sure but in the ED, rate control and cards f/u as well, of course, as looking for any underlying issues is just fine.
In the Ottawa Aggressive Protocol article (CJEM 2010) 91.4% of patients were still in NSR at 1 week.
In this article, at 30 days the rate was > 80%
Many patients won't recur. Regardless, cards follow up is needed to assess for further management with either meds, or ablation.

Laryssa P. -

Thanks for great wellness pieces in the last couple of months. For wellness conversations with residents, are the PD/APD present? What are others doing at their programs?

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Red, Hot, and Shot Full episode audio for MD edition 237:30 min - 331 MB - M4AEMRAP 2017 May Aussie Edition Australian 22:03 min - 30 MB - MP3EM:RAP 2017 May Canadian Edition Canadian 12:11 min - 17 MB - MP3EM:RAP 2017 May Spanish Edition Español 77:25 min - 106 MB - MP3EM:RAP 2017 May French Edition Français 23:24 min - 32 MB - MP3EM:RAP 2017 May German Edition Deutsche 73:18 min - 101 MB - MP3EM:RAP 2017 May Board Review Answers 211 KB - PDFEM:RAP 2017 May Board Review Questions 171 KB - PDFEM:RAP 2017 May MP3 Individual Segments 316 MB - ZIPEM:RAP 2017 May Written Summary 839 KB - PDF

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