Peter Antevy reviews the 2018 atrial fibrillation protocol update for prehospital care. Diltiazem stays first-line for stable rapid AF, but the interval for a second dose drops from 15 minutes to 5 minutes. In hypotensive patients, resuscitate first with fluids and push-dose epinephrine before giving diltiazem.
Questions this video answers
5 minutes (previously 15 minutes).
Fluid bolus and, if needed, push-dose epinephrine to establish a good baseline blood pressure.
Yes — once a satisfactory baseline blood pressure is established, diltiazem may be administered, and calcium may be given to mitigate arterial dilation.
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So let's go over the atrial fibrillation protocol update for 2018. Now remember, atrial fibrillation is a rhythm that we don't really want to shock in the field because they may have a blood clot in their heart. And if you convert them, that blood clot then may leave the heart and go to the brain and cause a stroke or to the gut and cause dead gut, etc. So what our goal for AFIB is is to bring a patient with good, stable blood pressure and relatively controlled rate to the hospital. So Cartizem is our first line drug here. And you'll see one of the first changes right at the top of the protocol is that you can give cartisam after five minutes. Rather, you can give the second dose of cartizam five minutes after the first dose. We used to make you wait 15 minutes, which is a long time, especially with our relatively short transport times. Now you only have to wait five minutes before you give that second dose. But let's say that you've got a patient that's hypotensive. And I get this question a lot. You have a couple of options on how you treat these folks that are hypotensive. Obviously, you're going to get fluid bolus. Let's say fluid bolus does not work well, then you've got your push dose EPI again and let's say you give your fluid bolus and, or your epinephrine and now you know what, you got a good blood pressure. The question comes up. All right, now that we fixed the low blood pressure, they're still going fast. Can we now move on to Carxam? And the answer is yes, Once you've established a good baseline blood pressure, you can give them the cartizam, keeping in mind that you may need to give calcium along with your Cartizam. And let me explain the reason for that in a second here. But one of the reasons why patients with AFIB that are going really fast are hypotensive is because their heart does not pause long enough to allow the heart to fill up with blood so they can have a good stroke volume. So as you bring the heart rate down, you actually often will see the blood pressure rise. Even though you're giving Cartizam, which is a drug that can lower their blood pressure. It's because you're making the pump much more efficient when you bring the rate down to a more reasonable rate. Now, Cartasome is a calcium channel blocker and it has two main effects. Number one, it slows down the heart. And number two, it causes the arteries to dilate. Now, causing the arteries to dilate can cause hypotension. That's why we have the calcium in the protocol. The calcium, when you give it, reverses the cartasom's effect on the arteries way more than it reverses cardiovascular effect on the heart. So in effect, it basically gives cartasam slowing of the heart, but blocks the cartasam's dilation of the arteries. So it'll help mitigate your hypotensive effect from the cartisan, but still give you the positive effect of bringing the heart rate down.
