What is the ACLS Approach to Atrial Fibrillation? (Advanced Cardiac Life Support)

A week or so ago I re-certified in ACLS – Advanced Cardiac Life Support. ACLS is a set of emergency clinical interventions for cardiac arrest, stroke, respiratory arrest, etc., which is basically a step above BLS (Basic Life Support – formerly known as CPR). ACLS certification, in my case anyway, is done through the American Heart Association, and is only open to health care providers: doctors, nurses, dentists, advanced practice providers like PAs and nurse practitioners, EMTs, respiratory therapists, pharmacists, and so on.

I thought I’d write about it in this blog so people might know what to expect as far as the type of treatment they might experience if they have an unstable episode of atrial fibrillation.

I’m in permanent atrial fibrillation, so when I’m in one of these classes I’m glad I’m not hooked up to an EKG – I don’t feel like getting medicated or shocked!

ACLS deals with various problems using algorithms, so let’s look at the “Tachycardia with a Pulse Algorithm” which would generally apply to acute atrial fibrillation.

ACLS-tach

So basically we start with a person with a fast heart rate. Tachycardia is, by definition, a pulse over 100 beats per minute, but for ACLS purposes it generally means a pulse over 150 bpm. Obviously not all tachycardia (fast heart rate) is atrial fibrillation.

For this article I am not discussing the other types of tachycardia, even though they are in the algorithm. I assume most people reading this blog are dealing with atrial fibrillation.

The first step is to assess the patient, identify and treat any underlying cause, make sure the patient is breathing effectively, assist if necessary, and give the patient some oxygen.

Now the next step is very important – is the patient stable? Five things: 1.) Is the blood pressure too low? 2.) Is there altered mental status (confusion)? 3.) Is the patient going into shock? 4.) Chest pain? 5.) Heart failure?

Even though I am in atrial fibrillation, all the time, I don’t have any of these symptoms. But if the patient is unstable and have tachycardia, basically, they are going to be getting some electricity! That means synchronized cardioversion, and in the case of atrial fibrillation (see “narrow irregular”) that means 120-200 joules – that’s a big shock!

Check out this video of cardioversion for atrial fibrillation – yikes!

Notice that it says “consider sedation.” Sedation can be considered, but not if it interferes with getting the unstable patient shocked as soon as possible. If you go into unstable atrial fibrillation at a race expect that the sedation will likely be skipped and get ready to be ZAPPED.

Photo by Ted Friedman.

Photo by Ted Friedman.

This is for unstable tachycardia – that means the patient is in some sort of crisis that may eventually be life threatening.

For an episode of stable atrial fibrillation expect vagal maneuvers and a referral to a cardiologist. Vagal maneuvers include firm carotid sinus massage, coughing, gagging, valsalva maneuver (holding your breath and “bearing down”), and placing your face in ice water (snow also works). A lot of people with intermittent atrial fibrillation already know how to do this.

For a great article about her episode of unstable atrial fib see Run, Smile, Drink Water and Don’t Die – A Guest Post by JoAnna Brogdon.

I’d be very interested in anybody else’s experience with unstable atrial fibrillation and what type of treatment was administered. Please comment below. Thanks.

Advertisements

Does Drinking Coffee Cause Atrial Fibrillation?

coffeebeans

It has often been said that drinking coffee is related to developing atrial fibrillation. How about people who already have a history of atrial fibrillation? Can coffee trigger an episode?

A recent large study from Sweden shows that coffee consumption does not increase the chance of developing atrial fibrillation, even if quite a bit of coffee is consumed.

So coffee does not cause atrial fibrillation; not in people who have no history of atrial fibrillation.

But what about people who already have a history of atrial fibrillation? Can coffee trigger recurrence of atrial fibrillation?

The answer to that is probably yes, but more research needs to be done. In this study it was found that people who already had atrial fibrillation tended to drink less coffee than people without atrial fibrillation – probably to prevent triggering the arrhythmia.

As for me, I’m in permanent atrial fibrillation and it really doesn’t make much difference – I drink my normal amount of coffee and don’t worry about it.

Here are some excerpts from an article, by Colleen Mullarkey, in Consultant360:
coffeecan

After analyzing data from nearly 250,000 individuals, researchers found no association between coffee consumption and an increased risk of AF, according to the findings in BMC Medicine.

“This is the largest study to date on coffee consumption in relation to risk of atrial fibrillation,” says lead study author Susanna C. Larsson, PhD, associate professor in the Institute of Environmental Medicine at Karolinska Institutet in Stockholm, Sweden.

Larsson and her colleagues investigated the association between coffee consumption and incidence of AF in two prospective cohorts who had provided information on coffee consumption in 1997 and were followed up for 12 years—41,881 men in the Cohort of Swedish Men and 34,594 women in the Swedish Mammography Cohort.

Using the Swedish Hospital Discharge, they identified 4,311 and 2,730 incident AF cases in men and women, respectively, in the two cohorts. The median daily coffee consumption was 3 cups among both men and women.

In their analysis, the researchers found that coffee consumption was not associated with AF incidence, even in more extreme levels of coffee consumption.

They confirmed this lack of association in a follow-up meta-analysis that included both of these two cohorts along with four other prospective studies, which amounted to a total of 10,406 cases of AF diagnosed among 248,910 individuals.

“These findings indicate that coffee consumption does not cause atrial fibrillation,” Larsson says. “However, high coffee consumption may still trigger arrhythmia in patients who already have atrial fibrillation.”

While the researchers could not examine this possibility in the present study, they observed that participants who had AF at the time they completed the questionnaire about their coffee consumption drank, on average, less coffee (mean of 2 cups/day) than those who did not have atrial fibrillation (mean of 3 cups/day).

Data in the study suggests that some individuals who had AF at the start of the study may have quit drinking coffee or cut down their consumption because of an arrhythmic-triggering effect.

“Further study is needed to assess whether coffee consumption may trigger arrhythmia in patients with atrial fibrillation,” Larsson says.

Larsson SC, Drca N, Jensen-Urstad M, Wolk A. Coffee consumption is not associated with increased risk of atrial fibrillation: results from two prospective cohorts and a meta-analysis. BMC Med. 2015 Sep 23;13(1):207.

Now the next question: Does running really ruin your knees? (Ha ha)