The Tachycardic Patient

Question 1

You are the FY1 on call for the general medical wards. You are asked to review Mrs K - a 70 year old patient with a fast heart rate.
She was admitted 1 day ago with general deterioration and increased confusion. She is currently being treated for an upper UTI with IV antibiotics. She has a background of hypertension, AF and osteoporosis.
Her observations are:
HR 156, BP 121/78, RR 19, Sats 96% on air, T 36.8

a) Likely cause of her tachycardia?
b) How should you initially assess her?

Answer 1

a) Fast AF (no decompensation)

b) A-E:
Airway
-

Circulation

• Start peripherally: CRT, colour, temp, pulses, BP, JVP, heart sounds (murmurs?)
• IV access, bloods (FBC, CRP, UEs, TFTs, ?troponins, ?D-dimer)
• IV fluids? (assess volume status)
• HR and BP monitoring (cardiac monitoring)
• Do an ECG
• Urine output - catheter?

Question 2

How to differentiate between arrhythmias.

Answer 2

• Narrow-complex or broad-complex
• Supraventricular or ventricular
• Regular or irregular

Question 3

Management of fast AF.

a) Not decompensated
b) Decompensated

Answer 3

a) A-E

Drugs:

• BB or CCB for rate control first line
• Digoxin
• Chemical cardioversion (eg. fleicanide, propafenone, amiodarone)

*fleicanide and propafenone contraindicated in structural heart disease

DC cardioversion only if:

• Acute (< 48h)
• Anticoagulated for > 4 weeks
• Emergency

b) Decompensated:
- Cardiovert