Download Rose ED AFib Algorithm

Rose Medical Center ED Atrial Fibrillation Algorithm
Addendum B
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Initial Assessment
AFib symptoms detected in triage
Immediate EKG (Within 10 min) and notify attending provider
Assess patient’s symptoms and hemodynamic status: palpitations, dyspnea, chest pain/discomfort,
fatigue, dizziness, hypotension, mental status, etc.
Acquire vital signs and apply oxygen
Labs to be done: CBC, CMP, TSH, Mag, PT/INR
Consider Echocardiogram if not already completed
TO BE DETERMINED BY ED PROVIDER
Atrial Fibrillation or atrial flutter?
Paroxysmal or new onset/newly recognized?
Persistent/Chronic with new rate problem?
Duration (< 48hrs or > 48hrs or unknown)
CHADsVASC Score (see up to date for reference on calculating)
o If ≥ 2, consider anticoagulation
Anticoagulated adequately already? – defined as on warfarin with INR ≥ 2 for 3 weeks or on another
DOAC for 3 weeks with no missed doses (**this changed from 4 weeks w the 2014 updated
guidelines)
Is the ventricular rate controlled?
Is the patient on antiarrhythmic therapy?
Recent symptoms of TIA or CVA?
Undiagnosed underlying condition (ACS, dehydration, acidosis, hypovolemia, sepsis, valve disease,
hypoxia, electrolytes, PE, recent surgery, ETOH, hypothermia, hypotension)
Signs of poor perfusion
(Uncomfortable or rate > 150 bpm)
 Symptomatic hypotension
 Pulmonary edema (acute heart
failure)
 Chest pain/angina
Rate or Rhythm Control
Strategy as outlines on
Pages 2-3
HEMODNAMICALLY STABLE?
YES
NO
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Consider urgent external cardioversion if AFib
believed to be etiology or contributing to current
instability - reference Addendum C and/or ACLS
tachyarrhythmia Algorithm on Crash Cart
Risk/benefit assessment required as it applies to
thromboembolism complications
Anticoagulation should be started as soon as possible
and continued for at least 4 weeks after
cardioversion unless contraindicated
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Rose Medical Center ED Atrial Fibrillation Algorithm
Addendum B
RATE CONTROL STARTEGY
ED
HEMODYNAMICALLY STABLE AFIB
Consider rate control FIRST for patients with Persistent AFib who:
 Have a contraindication to antiarrhythmic drugs
 Do not meet criteria for cardioversion
RATE CONTROL ASSESSMENT
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Assess underlying conditions that affect rate control (CHF, Hypoxemia, hypovolemia, sepsis, COPD,
thyrotoxicosis, etc)
Atrial fibrillation vs Atrial Flutter
Symptomatic?
HR > 100 or <100 bpm?
Symptomatic Rate > 100
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Consider IV diltiazem per
hospital approved protocol;
use caution if noted
decompensated CHF
Consider IV metoprolol
tartrate 2.5-5mg bolus over
2 min, up to 3 doses
If further rate control
needed, consider Digoxin
0.25 mg IV w/ repeat dose
to max of 1.5 mg over 24 hrs
Refer to ACLS
Tachyarrhythmia Algorithm
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PO AV nodal blocking agents
(beta blockers, diltiazem, or
digoxin). Use caution with
BB in pts with pulmonary dx
or known EF < 35%
IV drugs only if unable to
take PO
Refer to ACLS
Tachyarrhythmia algorithm
Rate control NOT ACCOMPLISHED, significant
ongoing symptoms or other conditions requiring
immediate attention
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Rate < 100
Asymptomatic rate > 100
Admission to telemetry floor
Refer to ACLS Tachyarrhythmia protocol and
Addendum C
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AV nodal blocking drugs
likely not needed if rate is
consistently controlled
(both at rest and with
exertion)
Rate control ACCOMPLISHED, no significant
ongoing symptoms and no other conditions
requiring immediate attention
Consider discharge with oral rate control and
OAC per their CHADsVASc score. Follow up as
outpt with PCP or cardiology
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Rose Medical Center ED Atrial Fibrillation Algorithm
Addendum B
RHYTHM CONTROL STARTEGY
ED
HEMODYNAMICALLY STABLE AFIB
Consider Rhythm Control FIRST for patient with persistent AFib who:
 Are symptomatic
 Have an AFib duration of 48hrs or LESS. If AFib has been present > 48 hrs, unless therapeutic
anticoagulation for the past 3 weeks can be verified, DO NOT attempt Rhythm Control without TEE
CHRONIC AND ADEQUATE ANTICOGULATION?
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Defined as on warfarin with INR ≥2 for 3 weeks (**this is a change from 4 wks w/ the 2014 updated
guidelines) or on a DOAC for 3 weeks with no missed doses.
NO
YES
DURATION OF AFIB < 48HRS
YES
DURATION OF AFIB >
48HRS or UNKNOWN
NO
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Significant ongoing symptoms or other
conditions requiring immediate attention
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Consider external
electrical cardioversion
or
Consider pharmalogical
cardioversion
Anticoagulate per
CHADsVASC score
Consider starting
antiarrhythmic
medication with
cardiology consult
Evaluation of structural
heart disease +/coronary eval, if not
previously done
Rhythm control ACCOMPLISHED
and/or no significant ongoing
symptoms and no other conditions
requiring immediate attention
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Consider emergent DCCV
– see addendum C
Consider TEE guided
electrical cardioversion
Consider pharmalogical
cardioversion
Anticoagulate per
CHADsVASC score
Consider starting
antiarrhythmic
medication with
cardiology consult
Evaluation of structural
heart disease +/coronary eval, if not
previously done
Admission to telemetry
floor
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Consider external
electrical cardioversion
or
Consider pharmalogical
cardioversion
Anticoagulate per
CHADsVASC score
Consider starting
antiarrhythmic
medication with
cardiology consult
Rhythm control ACCOMPLISHED
and/or no significant ongoing
symptoms and no other conditions
requiring immediate attention
Consider discharge with oral
rhythm control and OAC per
their CHADsVASc score. Follow
up as outpt with PCP or
cardiology
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