EMCrit Podcast EMCrit Podcast 20 – The Crashing Atrial Fibrillation Patient
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Dec 21, 2010 Scott dives into the urgent management of a crashing atrial fibrillation patient. He outlines immediate cardioversion strategies and discusses optimal sedation techniques. Learn about using push-dose phenylephrine to stabilize blood pressure and the pros and cons of rate-control medications like amiodarone and diltiazem. The importance of ruling out Wolff-Parkinson-White syndrome before administering AV blockers is also highlighted. Finally, he explores alternatives, including magnesium, if initial treatments fail.
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Shock High And Sedate Lightly
- When cardioverting an unstable AFib patient, start at the highest energy setting to maximize success.
- Use posterior-anterior pad placement if possible and consider light sedation (e.g., low-dose etomidate ± ketamine) before shock.
Use Push‑Dose Phenylephrine First
- Temporize hypotension with push-dose phenylephrine to maintain brain and coronary perfusion while treating rate.
- Aim for diastolic pressure around 60 mmHg and titrate 50–200 mcg boluses every minute as needed.
Perfusion Enables Rate Control
- The heart will not slow until you restore coronary perfusion, since poor diastolic pressure prevents filling.
- Vasoconstriction helps short-term but worsens systemic tissue perfusion, so it's only a bridge to definitive therapy.