Cardioversion

PATIENT PRESENTATION:
E.R. is a female in her 60s, who presented to the emergency department c/o palpitations and lightheadedness for ‘a day or so’.  Pt appeared slightly diaphoretic and tachypneic but denied chest pain.  Past medical history included HTN, smoking (unsure frequency/duration) and paroxysmal atrial fibrillation (3 episodes within the past year).  Medication reconciliation revealed that the patient was on metoprolol (25mg BID), propafenone (225mg BID) and ASA (81mg daily).  Vital signs: BP 145/110, P 145, RR 23, O2 96% on RA, T 98.8

DIFFERENTIAL LIST:
Atrial Fibrillation, Pulmonary Embolism

DIAGNOSIS:
EKG showed Atrial Fibrillation with a Rapid Ventricular Rate. 
Chest X-ray was done, results were WNL.
CBC, CMP, Cardiac Enzymes, D-dimer and Thyroid panel were drawn and sent to the lab. Only abnormal value was a slightly elevated BUN (22mg/dl)

Diagnosis was atrial fibrillation with rapid ventricular rate.

TREATMENT:
Pt was given bolus of diltiazem 5mg IV x 2, then started on diltiazem IV drip.  Minimal success was achieved with medications; heart rate dropped from 140s to 110s and remained in A-fib.
Pt was anti-coagulated with bolus dose of heparin IV, placed on heparin IV drip, as well as Enoxaparin® 100mg SQ q 12hrs.
Admitted to the ICU

OUTCOME:
Once the pt was adequately anticoagulated (aPTT 60sec), pt had a Transesophageal Echocardiogram done.  Results indicated a moderately enlarged left atrium and left ventricular hypertrophy, but no blood clots were visualized in the LA.  Patient was cardioverted right away with 100J using synchronized cardioversion. 

Pt converted to NSR but only for a few hours then went back into A-fib with RVR (P 110s).  Pt then received ibutilide 1mg IV over 10 minutes, and converted to NSR.  Pt remained in NSR, all IV drips were d/c’d and patient was started on a regimen of metoprolol 25mg PO BID, Multaq® 400mg PO BID and warfarin 5mg PO daily.  Within a few days the patient was discharged from the hospital with a scheduled EP study and ablation.
Case created by Elizabeth Richards, 2012.