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I'm coming up to my ACEM Fellowship exam later on this year and as part of my exam practice I'm trying to consider the ECG of the Week in a VAQ format.
With this in mind I'll be adding an exam style question with each ECG of the Week from now on for people to consider. I won't be directly answering these questions on the blog but hope they give a different spin on how our reader's can use the blog and ECG's.
For those of you not coming up to exams it might just be a bit of fun :-)
Question:
47 year old female presents complaining of palpitations onset 3 hours age. She denies chest pain and is not short of breath. She has no prior medical history. Blood pressure is 120/75.
Her ECG is above.
a) Describe and interpret her ECG (30%)
b) Outline your management options (70%)
a) Atrial fibrillation with a rapid ventricular response, rate of 150-190 (some sections are roughly regular and this may be a stretch of fib/flutter)
ReplyDeleteb) Rate and/or rhythm control with the appropriate anticoagulant.
Rate: Classic options include Ca-channel blockers such as diltiazem (0.25 mg/kg slow IVP) or verapamil (5 mg slow IVP) and B-blockers such as metoprolol (5 mg IVP).
Rhythm: IV procainamide (1 gm over 60 mins) as part of the Ottawa Aggressive Protocol has also been shown to be effective at the termination of acute atrial fibrillation or flutter. IV or PO amiodarone has some support from meta-analyses in acute AF, although this is not my option.
If antiarrhythmic therapy fails to convert the rhythm, cardioversion is next, although elective cardioversion may be considered first line which is also safe and effective. However, if relatively asymptomatic, rate control alone with d/c Rx of B-blocker and anticoagulants can be considered as AF may spontaneously terminate.
Anticoagulant would typically be warfarin, although many other options exist and the literature notes a very low incidence of thromboembolic events with the termination of acute AF.
That being said, I'm way more familiar with the field Rx :-)