Queen's University Internal Medicine Simulation Course

Queen’s University Internal Medicine Simulation Course
Case: Rapid Atrial fibrillation
Synopsis:
75 yo M admitted to hospital with pneumonia develops rapid a. fib overnight.
Number of Participants:
1 – 2 senior medicine residents
Objectives:
Management of both stable and unstable a. fib.
Crisis resource management in the setting of critically ill medicine patients
Stem:
75 yo M admitted yesterday with 3 days of progressive SOB, cough, and fevers.
Physicial exam shows right sided crackles and hypoxia. CXR confirms RML infiltrate.
Patient placed on O2 and admitted to the floor. This evening develops sudden
increased SOB and palpatations, while returning from a smoke. No chest pain, no
fevers, no chills, remainder of
Roles:
1) Primary Senior Internal Medicine Resident
2) Secondary Senior Internal Medicine Resident (optional)
3) Nurse
Script for Roles:

Nurse: Patient returned from a smoke and has increased SOB. You call the resident to
assess.
Scenario Setup
Setting: Hospital Cardiac Sciences Unit
Manikin: Hospital gown, 20 gauge peripheral IV saline lock
Resources:
Initial Parameters:
Patient: Patient uncomfortable, SOB, but able to answer questions.
Past Medical History:

1. CAD
a. NSTEMI 2003 with RCA stent,
b. NSTEMI 2010 with LAD stent x 2
2. CHF – secondary to ischemic cardiomyopathy, EF 45%
3. Dyslipidemia
4. HTN
5. COPD – FEV1 59%
Social History:
Married with 2 children, lives at home with wife, worked as a mechanic, no
alcohol or drugs. > 50 pack year smoking history
Medications:
 Metoprolol 25mg po BID
 Ramipril 10 mg po Daily
 ASA 81 mg po Daily
 Plavix 75mg po Daily
 Lipitor 40 mg po Daily
 Spiriva 18mcg 1 puff inh Daily
Physical Exam:
Vitals: HR 165 BP 95/50 RR 22 Temp 36.7 C O2 sat 93% on 3L
Resp:Crackles at bases R > L
CVS: Normal S1, S2, no murmur, mild peripheral edema, elevated JVP
Abdo: Soft, not tender, no masses
Labs: AM Bloodwork (K Normal at 3.6) (Mg Normal at 0.86)
CXR: None
EKG: STEMI in inferior leads with bradycardia at 45

Scenario Flow Chart
Vitals: HR 165 BP 95/50 RR 22 Temp 36.7 C O2 sat 93% on 3L
All other management

decompensation
IV b-blockers, CCB, dig, or aminodarone, Patient

unchanged
Repeat IV b-blockers, CCB, dig, or aminodarone,

patient worsening
Electrical cardioversion, patient returns to sinus

rhythm and then back to a. fib
Repeat IV medications, continued instability
Patient scanned for PE anti-coagulation

started
Checklist:
□ Identified a. fib
□ Placed patient on monitor
□ Placed on O2
□ Obtain EKG
□
Indications for urgent cardioversion
•Active ischemia (symptomatic or electrocardiographic evidence)
•Evidence of organ hypoperfusion
•Severe manifestations of heart failure (HF) including pulmonary edema (see "Atrial fibrillation in
patients with heart failure")
•The presence of a preexcitation syndrome, which may lead to an extremely rapid ventricular rate
due to the presence of an accessory pathway
Treatment options
•Beta blockers or verapamil or diltiazem are the preferred drugs in the absence of HF, since
digoxin is less likely to control the ventricular rate during exercise (when vagal tone is low and
sympathetic tone is high), has little ability to terminate the arrhythmia, and often does not slow the
heart rate in patients with recurrent AF.
•Intravenous amiodarone may help control rate when the other drugs are ineffective or cannot be
given.
•Digoxin is the preferred drug ONLY in patients with AF due to HF. In addition to the direct
vagotonic effect of digoxin on the atrioventricular (AV) node (which may require several hours to
become apparent), the improvement in left ventricular function and systemic hemodynamics
result in withdrawal of sympathetic tone and a further decrease in the ventricular rate. Not
infrequently, the improvement in hemodynamics results in reversion of the arrhythmia. Digoxin
can also be used in patients who cannot take or who respond inadequately to beta blockers or
calcium channel blockers. The effect of digoxin is additive to both of these drugs.
•Procainamide IV is recommended for rate control and for attempt to cardiovert atrial fibrillation
with preexcitation when urgent cardioversion is not available or recommended. Intravenous
amiodarone is an alternative option. Intravenous AV nodal blockers, in particular digoxin and
verapamil, are contraindicated in patients with atrial fibrillation and preexcitation.

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Queen’s University Internal Medicine Simulation Course

Case: Rapid Atrial fibrillation

Script for Roles:

Setting: Hospital Cardiac Sciences Unit

Manikin: Hospital gown, 20 gauge peripheral IV saline lock

Patient: Patient uncomfortable, SOB, but able to answer questions.

Past Medical History:

Labs: AM Bloodwork (K Normal at 3.6) (Mg Normal at 0.86)

EKG: STEMI in inferior leads with bradycardia at 45

Vitals: HR 165 BP 95/50 RR 22 Temp 36.7 C O2 sat 93% on 3L

All other management

IV b-blockers, CCB, dig, or aminodarone, Patient

All other management

Repeat IV b-blockers, CCB, dig, or aminodarone,

All other management

Electrical cardioversion, patient returns to sinus

All other management

Repeat IV medications, continued instability

Patient scanned for PE anti-coagulation

□ Placed patient on monitor

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