#AFib RVR

[mcatmemoranda]

If a pt with liver failure has varices, you automatically prophylax against SBP with ceftriaxone. It's 1 g IV q24 x7 days.

If pt has renal failurem be cautious regarding K+ repletion--the kidneys remove excess K+ so if your kidneys are failing, then your body has a harder time removing K+. So instead of repleting a K+ of 3.2 with potassium chloride 40 mEq x2, you would give like 50-75% of that so you don't make the pt hyperkalemic.

Anti-pseudomonal: piperacillin-tazobactam, fluoroquinolones (e.g., levofloxacin), aminoglycosides (e.g., gentamicin, amikacin).

Osteomyelitis is usually diagnosed by MRI. But if you see it on a CT scan, that is sufficient.

A pt with renal failure and liver failure went into AFib with RVR this morning. Her BPs are low with SBP in the 90s. You don't give metoprolol 5 mg in somone with a low BP. You don't give diltiazem either. Our attending suggested amiodarone (dose for AFib is 150 mg IV x1 over 10 minutes, then 1 mg/min IV x6 hours, then 0.5 mg/min IV x18 hours). We consulted cardiology, who said amiodarone is not a good choice in the setting of hepatic dysfunction; sotalol would complicate management of hypotension. They recommended anticoagulation given her CHADSVasc of 3. Echo is pending and it's worth checking serial troponins. Also check TSH.

[macgyvermedical]

hii! what are the effects of prolonged tachycardia with fluctuating bpm ranging from 140-160 for around 30 minutes to a conscious patient? will it cause any brain damage?

The short answer is basically nothing and no.

Tachycardia is any heart rate above 100 in an adult. There are several different kinds of tachycardia, including sinus tachycardia, paroxysmal supraventricular tachycardia, atrial fibrillation with RVR, and ventricular tachycardia. Whether the tachycardia is bad for a person has to do with what kind of tachycardia it is, what the heart rate is, and how long the person is in that rhythm.

The first one we'll talk about is sinus tachycardia. Sinus tachycardia is a normal physiological response to the body's demand for more oxygen and nutrients. Sinus tach happens when someone has a fever, is dehydrated, has blood loss, is in shock, or is having a strong emotional response.

It's one of those things that doesn't need treated in and of itself, though figuring out and treating the cause is important. Once the cause is treated, the heart rate usually drops back down to normal.

There are also times when you intentionally bring the heart rate up above 100- for example, exercise. This is also considered sinus tachycardia. When you exercise, you want your heart rate to be in a target zone, which depending on age can be anywhere from 75-170bpm (the younger you are, the higher the target heart rate).

In the case of exercise, a heart rate of 140-160bpm for a half hour would be completely reasonable. In the case of dehydration or shock, you'd really need to fix the problem, but the heart rate itself isn't going to hurt anyone under about 60 who is otherwise healthy.

Paroxysmal Supraventricular Tachycardia (PSVT) is a condition in which the heart rate randomly increases into the high 100s-low 200s. This heart rate is so fast that the heart doesn't have time to fill with blood in between beats. Because of this, not as much blood is getting out of the heart to the brain and body, which means the person may feel faint, short of breath, or dizzy or even pass out.

People in PSVT may spontaneously convert back into a normal rhythm, or they may need a drug called adenosine given to change them back to a normal rhythm. Adenosine works kind of like a defibrillator- it briefly stops the heart in order to let it restart normally. If this happens frequently, someone may need an ablation- a procedure in which parts of the heart muscle that are causing the rapid heart rate are burned to permanently prevent future attacks.

In order to understand atrial fibrillation with RVR, you have to understand how the heart initiates beats normally. In the heart there are cells in a place called the SA pacemaker node, which send out small electrical signals that work to coordinate a beat across all the cells in the heart.

In atrial fibrillation, lots of cells outside this node try to initiate beats, which causes the top half of the heart to quiver. If a lot of these "beats" get through to the bottom of the heart, that's called Rapid Ventricular Response, or RVR. Afib RVR causes a rapid, irregular heart rate.

Afib RVR can cause the same problem as PSVT- namely that it causes the heart to beat so fast it can't refill with blood in between beats. Usually the first few times this happens the person converts out to a normal rhythm within about a week (or can be converted out with defibrillation or medications). Later this state can become permanent and has to be managed with medications that reduce the heart rate and blood thinners to prevent strokes and heart attacks, which happen because blood gets stuck and clots in the quivering upper part of the heart.

The last one, ventricular tachycardia, is the most dangerous because if not treated it can either become so fast virtually no blood is coming out of the heart (cardiac arrest) or become another dangerous rhythm called ventricular fibrillation (also cardiac arrest, but even worse).

This one is a life-threatening emergency and needs to be treated immediately with CPR (if the person is unconscious) defibrillation and medications.

This was a lot to answer your question, but all this to say that if your person is running 140s-160s because they're working out for a half hour, they're totally fine. If they're 140s-160s because of PSVT they're not fine but they're probably going to convert out of it with a medication or just time. If they're 140s-160s in RVR they're probably uncomfortable and need medical attention but they'll probably be alright. If they're in ventricular tachycardia, they need emergency care.

Of these, the only one that could really cause brain damage is the ventricular tachycardia, but it would have to be a lot faster than 140-160.

[pleasedotheneedful]

waiting awkwardly at bedside during a very long rapid response for afib/RVR

nursing: here, try blowing into this straw

resident: I don't think it's gonna do anything, he's in afib--

me: sshhhhh it gives the patient something to focus on

...

resident: ohh, I guess that's one of those attending insights huh?

[thebigbiwolf]

Haven't been posting here because I've been dealing with some health stuff and had an "AFib with RVR" episode in a fucking AutoZone with a bpm of 190 which landed me in the hospital and now I'm feeling generally weird about life because Im sort of like a walking stroke risk rn until I can see a specialist next week(?). anyways.

[freshrn]

Inside CVICU Nursing: A Veteran's Guide with Jeannie Cisney

In this interview, Kati chats with Jeannie Cisney, MSN RN. She is a 20+ year veteran of the CVICU (cardiovascular intensive care unit). We discuss:

The types of patients you’ll see in a CVICU

Her favorite and least favorite types of patients

A walkthrough of the patient pathway of a typical CABG patient

New grad vs. experienced nurse orientation experience into CVICU

Unexpected challenges of CVICU RNs

The advice she’d give her younger self

Jeannie is my co-author of Cardiac Confidence, a Crash Course for New Cardiac Nurses. To learn more and enroll, click here: https://courses.freshrn.com/p/cardiac-confidence 

For a 14-page ECG cheatsheet: https://bit.ly/3Ws75NT

For a free mini-course on how to handle afib with RVR: https://courses.freshrn.com/p/afib-with-rvr 

For my cardiac assessment checklist: https://bit.ly/4aV6RTO

For ALL of our cardiac content: https://www.freshrn.com/cardiac-nursing/ 

Learn more about the FreshRN All-Access Pass here - https://courses.freshrn.com/p/membership

To see our latest course catalog (med-surg, ICU, precepting, charge nurse, ortho, cardiac, neuro courses, and more), click here: https://courses.freshrn.com/

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Music credit: Keep My Cool by Benj Heard

  Check out this episode!

[wingwongwangagain2]

Day 5

Last day! I really wanted to keep my badge but I was unable to :[

Its okay I took a picture of it.

Prison Cowboy.

VSS - vital sign stable

As we were chart reviewing today, we talked about stroke risks, considerations of possible stroke, will require imaging, acute stroke - CT scan, sub acute - MRI

Preview of what kind of pts we saw today. lady was hit by a car when she was on her ATV at highway speeds that was trying to throw away her spoiled meat. She lives on a ranch of 5000 acres.

We had some renal pts today.

obtunded - non-arousouble

syncope - pass out/ fainting - precaution to watch out for vitals esp bp.

HD - hemodialysis

Renal pts- watch out of diaylsis schedule, electrolytes, fluids, vitals

want to consider seeing with OT because if pt goes into afib- RVR they can be able to generate a eval for both pt and ot instead of unable to do it for either or and wait until pt is stable again.

first pt we saw was a renal pt, we co treated this pt was kristy w. She was pretty new, but she was kinda fine. but we sat the pt on the commode but she was just going for a while and courtney was like uh i cant wait for you to finish so she left.

second person we saw was the bald dude with the weird head shape that broke both his legs in a car accident. non weight bearing t transfer dude. but we cotreated with emily k and we slide boarded him into a wc. we did wc training with him and he was all mentioning that someone rigged his car, but that was probably his tbi coming through.

next i parted ways with courtney and i started shadowing jesse. it was interesteing. i was seeing an old lady that had a fall that broke her mandile in two places and dislocated her tmj that had a wire as well as a close reduction of her tmj. it was fine jesse did a quick tinetntti on her and she was on a all liquid diet because her jaw was wired shut.

jesse mentioned that his outcome measures are usually documented by exclusion in acute care.

a tip is to tie the socks on the end of the bed rails

next we had a tbi mexican dude. he had a massive TBI, he was high on cocaine and ETOH had a liver laceration colon repair and a bunch of other stuff. jorge. his right side was paralyzed. he was rancho 5? 4-5. he was unable to fully communicate but communicated a little bit, minimally responsive. he had a trach and a tube feed. peg tube.

jesse said to unplug it turn the knob towards the pt before unplugging or else it will leak. he was able to move around and had no tone or spasticity. jesse tried getting him up but he ended pooping him self and kept pooping. he jus got him back in to bed.

next we say eric. jesse was just overseeing jess and phil the ot treat his man. he had an anoxic brain injury, hypoxemia from his dm2 attach and had acute resportaory failture. he is 50 years old and also has cdiff. the whole time they got him up max assits to the chair and he was just turning his head and gasing side to side. he didnt let peoplke get close into his bubble and swatted them away. they were trying a lot of different things to illicit purposeful movement or response from him to get his attention to do something. it was a goal of habiuating with intetional movement. he was non verbal. i think they spend about an hour just in there trying to figure out what to do and plan of care and how to progress him meaingfully. they talked about how each doc keeps messing with his medication and his head turns are new. and previously he was doing well but he has declined. his mom tracked his medication and his good and bad days and they found and associatation with a certain drug. he was combative prevuiosuly.

he had invounltary head turns and movements

next i was back with courtney, we saw the lady that was hit by a car on her 5000 acre ranch on her atv. her l side was all messed up and had a clavicualur fx that made her nwb on her left side and nwb on her l lle. we just sat her on eob and thats it. she also had spine fxs

finally we saw the last lady chris, chocolate pudding lady. she was the similar condition with fistulas on her abdomen due to complicatins with gi stuff, like the fat boy with gsw. she has a wound manger in her intestntine. she previously had an ex lap that intesntine surgery. she pooped and then we walked her and went into the kitchen for her to grab stuff. then walked to the window and rested and her husband came iwht wendies frosties. we co treated with emily k. ot. we just then walked her back and sat her down.

different types of feeding tubes,

NG- nasogastic

NJ- naso jejunal

J tube - jejunal tube

peg tube - percutanenous endoscopic gastrostemony (procedures)

G tube - goes into stomatch

lopex valve

bumper and peg tube

entero-entera lfistula

gastrointestinal fistual

ostomy bag

medicare is the best for 65 and older, approves everything like rehab. private as secondary.

privates for 65 and younger sucks because arounf 50-65 they deny ipr alot

bed rails all 4 is restraint 3 is ok.

[healthcareinsights-nd]

Read more on observation care from MCG paoer

downloaded in document section of Tablet

How money works

Managing bed days

Hospital goes to commercial payer

Approval of payment

Clinical crietria

Nurse gives report read doc notes

PNA 3 days, Cellulitis 2 days, Scoliosis 5 days

No one can predict

Takes turn for worse.

PNA goes to pneumonia edema Afib with Rvr

Dripper

Nurse calls again

Pays for 3 days, denies 2 days, pt gets bill for $20k

How do they get in hospital

Er

Ins notification

7 days a week 24 days

Case managers holidays

Did not notify

Elective surgery

Not emergency

PA for these many days

Who decides

#Interqual largest approval date associated with UHG, McKesson, evidence based. What evidence. Circular reasoning. Specific study, criteria, propertiary, registered non physician. 1000..break up, Laura Coughlin BSN no clinical evidence. Monique Yahannan.

#MCG care guidelines Milliman Care Guidelines

Hearst health. Media company.

Bed day standardization in healthcare

Traditional Medicare uses DRG.

How long you stay does not matter. Pay you x amt.

2k per member per year

300b commercial

100b Medicare Adv

400 b goes thru UM

1m providers managed by 1000 powerful MDs and NPs. Huge financial pacts

Who made them king

Negotiate. Hospital ve to agree.

Ins carriers are real sticlers

Replace with InterCare or McGQual.

InterQual Evidence based content

Atrius health uses InterQual to make decision confidently about hospital at home for pts against inpatient hospital setting.

Review labs, imaging

Available modules in Interqual

[crazymadpoet]

I’ve had better days. An ambulance took me to the hospital this morning. Afib with RVR is no laughing matter. My heart was over 150 bpm for almost 4 hours. https://www.instagram.com/p/CjTOYN_pae1/?igshid=NGJjMDIxMWI=

[lamentations44]

Interesting ECG from my admission today. Started out atrial fibrillation with rapid ventricular response ( afib with rvr) and you will notice that half way through he changes morphologies and went into a (pulseless) ventricular tachycardia (VT).

[populationpensive]

Conflicted

So I got an admission this morning who was super hypoxic. She is a DNR/DNI and VERY sick at baseline. Literally all the problems (HfrEF, COPD, GI bleed, clotting disorder with active DVTs on heparin, PVD, HTN, HLD, GERD, RA, CAD, Afib, breast cancer).

She came to me on a BiPAP barely saturating 83%. The internist said they were concerned about aspiration and I was like "ok then BiPAP actually isn't a good option because it just shoves everything down." She is in Afib with RVR with HRs 140-160s though maintaining her BPs. She is extremely uncomfortable. I confirm that she doesn't want intubation. Then I switch her to high flow nasal cannula and she does better for maybe 20 minutes but ends up getting REALLY hypoxic. She got as low as 69%. So back on BiPAP she goes and she hangs out in the 75-85% range.

Now, interestingly, she is still alert and oriented even with such low saturations. I explain to her that I'll do all the respiratory/medical/non-invasive stuff I can but that ultimately to correct her hypoxia she would need intubation. She declines. I explain that she could die if her oxygen does not improve with BiPAP. She expressed understanding of this. I explain that I can keep giving her all her meds or she could opt to be comfortable. In the comfort case, I'd give her morphine and get rid of anything that doesn't support comfort. She said she wants to be comfortable and see her family.

So, I make her "comfort care", delete all the meds, then call her family and update them. The patient had this interesting affect/realization of "yes I know I've been slowly dying."

The thing I feel conflicted about is that I don't think I did a good enough job explaining her medical options. I kind of laid it out as either "this" (all the things) or "that" (comfort). Really, there can be an in between. I could still continue her antibiotics and such. I'm worried I jumped the gun and didn't explain things well enough. Also feel like I didn't discuss with her that the BiPAP would probably come off at some point. She expressed a wish to see her family and I explained to her that I wasn't sure if she would survive that long. I kept the BiPAP on to at least give her a chance of that.

I have a personal bias that I freely admit where I believe people with severe comorbidities who acutely decompensate should opt for comfort. I know that about myself, for better or worse. And I also know that sometimes when you give patients too many options it is overwhelming. Sometimes you have to be simplistic. I guess what I don't want to happen is have her family come and be like "well you just MADE her comfort when REALLY all she wanted was to breathe better."

When I left, my patient was sleepy after getting morphine but it did help her breathe better. Her tidal volumes are still trash but at least she was getting better saturations. It's not sustainable but at least she is cozy now.

I guess the other thing that pushed me in this direction was that the patient was DNR/DNI. So, she's not unaware of how sick she is. She clearly values a quality of life that doesn't involved unnecessary stuff. ...I just wish I was more explicit.

I guess I don't want it to seem like I gave up on her or didn't try. And I don't want it to seem like I misrepresented what was going on, though I could have been more clear that her respiratory issues could be due to a reversible cause and that she could do better, potentially, though I doubt that with her severe comorbidities.

I mean...she was SO hypoxic and not making improvement. 100% FiO2 on BiPAP. 84% SpO2. Not sustainable.

So. Here is anxiety Poppen, sitting and worrying about it. I shared my concerns with the day team and they said they would readdress everything. It's not like we can't add her meds back on if she wants more workup. It's just...when I sit and think about it...I could have ultrasounded her heart and lungs. I could have done more investigating instead of being like "shit your saturations have been less that 84% basically since you got here (2 hours) this looks like this is it." I literally told her that I was worried she was actively dying and she was like, "I know, I have been."

*sigh* I don't typically take work home with me in this way. I think since I have started my ICU job in February I've had 2 other occasions where I came home being like "did I make the right decision?"

I feel like in her case, with how sick she is as baseline that comfort is the best option. And she said she wanted that. I guess I just feel like I didn't give her enough information to make the most informed decision. :-/

Update/Edit: bless the day team for contacting me and telling me that family was in agreement and that the patient wouldn't want any more intervention. I think this just serves as a learning point for me to be more clear. I can explain in between options without making it complicated. I'll be more diligent about this, especially in emergent situations, in the future.

[mcatmemoranda]

Magnesium sulfate can be used for ventricular arrhythmia. I didn't know this. Had a pt who came in with new onset AFib with RVR and they gave him 2 mg mag sulfate in the ED (in addition to starting heparin [4000 units once and then 11 units/kg/hour] in anticipation of TEE cardioversion), and diltiazem gtt (25 mg IV once, then 5 mg/hour; overnight resident titrated it up to 10 mg/hour).

[psychokangaroo]

That moment when you think the patient is gonna be a simple covid pneumonia but you just keep on finding things like afib with rvr and mildly elevated trops then hyponatremia now he had a 2pt drop in Hg in a week and its just... omfg

[hangrypa]

table rounding w hangry

Me: Alrighty, in Room 1, we have Mr. Smith. He is a 63y/o male with a history of Afib and Takotsubo cardiomyopathy who presented with flash pulmonary edema and DVT. Cardiology is following. Following extensive diuresis and an increase in his home metoprolol, he is no longer in RVR and now satting mid-90s on room air. Once we get the prior auth on his Lovenox, he can go home.

Attending: Perfect.

Me: He also has an adorable bulldog at home.

Attending: Ah.

Me: Okay, next up in Room 2, we have Ms. Jones. She is a 74y/o female who received allogeneic stem cell transplant about 2 months ago and presented with rash and diarrhea suspicious for diarrhea. Heme/Onc is following. She is on Methylprednisolone with significant improvement in stool volume, now putting less than 500ml out. Her rash originally was ~50% BSA and is now about 20%. She will be discharged on Prednisone taper, pending Heme/Onc recs.

Attending: Good.

Me: And she has a little goldendoodle at home.

Attending: Nice.

Me: All right. Then in Room 3 is Ms. Williams. She is a 67y/o female who presented with urosepsis secondary to new kidney stone. She's had a wild hospital course and was extubated just 2 days ago. It appears that she also is now deaf. We've consulted ENT, and they suspect vestibular neuritis. I reached out to them to ask about starting steroids. She likely will not be returning home for at least another 48hrs while we sort this out.

Attending: I see.

Me: She has a giant derpy mutt at home.

Attending: I take it that you like dogs.

Surrounding coworkers: [in unison] YEP!

[medschooltutors]

Check it out! We’ve got another Instagram question panel series for you! Please let us know what you think. Happy Studying!

[randommomentsdevida]

2nd day being pulled to the unit for coverage.

I'm exhausted.

Not so much from the covid pts, but the stupid questions from the medicine interns

"should we get PT/OT on this pt who's paralyzed?"

Almost going to be a medicine senior and can't manage afib with rvr

Do I put the drips on sign out that aren't running?

[commonrn]

When I tell the resident the patient has gone into AFIB RVR and the response is “are you sure it’s not just sinus tach?”