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Extra resources for Acute medicine
Call for specialist advice rather than ‘having a go’. A 76-year-old woman is brought to the Emergency Department by ambulance having been found collapsed in her kitchen at home by her son when he went round to visit in the morning. She is normally independent and lives alone. She has a past medical Atrial fibrillation Many patients with atrial fibrillation of recent onset will eventually cardiovert to sinus rhythm irrespective of the treatment strategy used. These patients are at risk of stroke and antithrombotic therapy takes priority over the If a patient is known to be in permanent atrial fibrillation and the ventricular rate is poorly controlled, a rate-control strategy should be used.
If this is the case, immediate transvenous pacing is not necessary and an elective decision on the need for a permanent pacing system can be taken. Close observation and cardiac monitoring is mandatory. If a patient is tolerating the bradycardia, then temporary transvenous pacing is almost certainly not needed. If the patient is unwell Immediate temporary cardiac pacing may be required if the patient is symptomatic. Marked bradyarrhythmia in someone who has suffered loss of consciousness, albeit transient, is almost certainly an indication for cardiac pacing, and the decision between a temporary transvenous procedure or the emergency insertion of a permanent system depends on local resources.
Echocardiogram: left ventricular function and other anatomical abnormality. Management Tachycardia causing haemodynamic compromise in an unstable patient Synchronised DC cardioversion is required: the energy levels will depend on the underlying rhythm, the type of defibrillator (biphasic or monophasic) and whether the patient is on digoxin. • Atrial flutter/SVT: 25 J (monophasic). • Atrial fibrillation: 100 J. • Ventricular tachycardia: 100 J. If cardioversion is unsuccessful, try moving the paddles to the anterior/ posterior position with one paddle over the heart apex and the other below the right scapula to the right of the spine.
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