ECG Question for the Day

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Based only on the rhythm in this 12 Lead, would you cardiovert this patient? As they say in the NREMT tests, don’t read too much into the question.

Slow Flutter-sm

Here is the long awaited update. Sorry for the delay, I’ll have my wimpy excuse in a post tomorrow.

Yes, the ED decided to cardiovert the patient. Why, I don’t know unless there was something else going on that I don’t know about. I just can’t think of what that might be as the ventricular rate was certainly well in control. Anyway, here is the post cardioversion 12 Lead.

Slow Flutter - post cardioversion-sm

So now, it just looks a first degree AV block. Maybe it isn’t but other than vanquishing the ugly looking Flutter waves, was there any benefit to the patient?

9 COMMENTS

  1. Well, I might. But that doesn’t mean EMS should.

    Perhaps the patient was recently diagnosed with Aflut, and the docs wanted to see if they could convert the rhythm, and thus spare him life-long anticoagulation therapy. Or perhaps, like many AFib patients, the patient felt symptomatic at this “normal” rate – many AFib patients describe feeling crummy at rates < 100. Or perhaps the patient's cardiologist thinks an occasional jolt is better than chronic rhythm-control meds, with nasty drugs like amiodarone PO.

    Anyways, a lot of "maybes" on my part. I'm interested to hear about the whole picture, what happened – perhaps that will explain things more.Thanks!

  2. Just saw your update.

    Depending on where you practice, ED cardioversion of stable fib/flutter can range from commonplace to non-existant; very different from our EMS perspective where we only think about unstable patients. The usual goal is symptomatic improvement and improved quality of life (e.g. maybe now the patient is able to walk up stairs without being winded). It’s an extremely nuanced and debated topic, but combined with Brooks’ post above, some of the key points are:

    Pro-cardioversion
    – Everyone responds to AF differently, and whereas some folks tolerate it quite well, others are highly symptomatic at even normal rates.
    – If it’s recent onset (<48 hrs), ED cardioversion has been shown to be very safe in well-selected patients.
    – Success rates (at least short-term) are very high in recent-onset AF, and electrical cardioversion carries less side effects than medical cardioversion as long as it's in a safe environment and performed by experienced and comfortable staff.
    – If I were to go into flutter tomorrow, I would elect for immediate ED cardioversion and D/C home.

    Con-cardioversion
    – The natural course for lots of lone-AF cases in younger folks (i.e. <50yo) is spontaneous cardioversion without treatment. As Rogue Medic would point out, we sometimes rush to try and fix the patient before they have a chance to fix themselves.
    – Although short-term success of electrical cardioversion is high, the other natural course for patients who experience new-onset fib/flutter is to eventually go back into the rhythm again down the line, eventually with more permanence. Sometimes it's days, weeks, or even years later, but once you have one episode of AF you're likely to experience it again. Why perform the procedure for a short-term fix when it's not going to stick.
    – Several studies have demonstrated similar safety and quality-of-life for both cardioverted and rate-managed AF.
    – You may be able to trust the onset time (less than 48 hrs) of the 30yo who describes a sudden arrival of symptoms, but studies of Holter monitors show that many patients are extremely poor at realizing when they go in and out of a-fib. Unless you can pin down a definitive time of onset, you're running the risk of cardioverting someone with significant atrial clot.

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