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.

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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.

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Next Event – Vernonia Marathon Sunday, April 13, 2014

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Training on the OC&E near Sprague River, Oregon

I’ve signed up for a Spring marathon – specifically the Vernonia Marathon. It is in Northern Oregon – North and West of Portland – a part of the state that I have never visited. I think this might be my 18th or 19th marathon but I’m not sure.

I just did my first true long run and I feel pretty good. I informally classify runs like this: two to six miles are shorter runs, like mid-week type runs. Medium long runs are nine to twelve miles. I’ll usually try to do a nine to twelve mile run every weekend even if I’m not training for anything. In fact, if I’m not training for anything at all sometimes that’s my only run of the week (with mountain biking or hiking on other days). I think of a true long run as being fourteen miles and up. There’s something about that distance that, for me, seems pretty serious. Anything over thirteen requires more fortitude.

I didn’t just start training for an April marathon this weekend – I’ve been training for weeks – but my weekend long runs have only been eleven to twelve miles.

As far as my atrial fibrillation is concerned nothing has changed – I remain in atrial fibrillation all the time, my running has slowed, and I need to make sure I drink enough water and eat something salty afterwards. After the fourteen miler I went through the drive through at Burger King and bought each of the dogs a cheap burger from the value menu (the dogs aren’t vegan), and just an order of fries (with salt) for me. This way I avoid the dizziness I sometimes get from standing up after a long run.

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Sophie Tired After a Long Run

The Vernonia Marathon course is on a paved bike trail. This is the first Rails to Trails project in Oregon – the OC&E Woods Line State Trail being the second. I chose it because I like to train on the OC&E and have completed the Bizz Johnson Marathon (on an un-paved rail trail) seven times.

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Sophie on Paved Portion of the OC&E Trail

I dislike running on pavement so hopefully there will be a dirt trail off to the side of the paved part. If not – well, a paved trail seems a lot softer because it is simply pavement on top of gravel as opposed to pavement on top of concrete (which is what our local streets are.)

I expect the Vernonia Marathon should be a small, informal, fun race and I won’t know anybody there except for my friend Claude who is also going to run it.

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Winter Training

My race strategy is to start out slow and then take it easy. The course profile looks hilly – but how steep can a rail trail be? Trains can’t go up more than a one or two percent grade, right? I think the hills will be gradual – like the Bizz Johnson course.

Funny – I always enjoy the training much more than the actual races.

If anybody has any experience with this event please comment below. See you there.

Heat and Salt and A Fib

As stated previously I get pretty lightheaded when I get up from a sitting position after a hard workout, particularly in hot weather. Orthostatic hypotension. I don’t know why I get dehydrated so easily now, but I have learned that I need to eat something salty and drink a lot of water  after a workout, particularly a run or a bike ride which is longer than an hour or two, otherwise I get pretty dizzy when I first standup, and I’ve had a friend who is an nephrologist and another friend who is an internist both tell me to make sure I drink plenty of water after a workout and get some salt. Just one more fun aspect of being in persistent atrial fibrillation.

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Pre-Race Motel

This is the first time in my life I’ve ever actually been trying to get more salt. Most people spend their lives trying to avoid salt. I have started bringing potato chips for a post run snack to the trailhead for my long runs. Another great post run snack is some blue corn chips with some hummus with some Hoisin sauce.

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Pre-Race

Although it is neither here nor there, I’d like to state that I am a vegetarian (nearly vegan – if not for the occasional veggie pizza) as far as diet is concerned.

I also find that I am more sensitive to heat, which is obviously related. Last summer I would often start to feel pretty tired 17 miles into a 20 mile training run. In cool weather a 20 mile trail run is no problem. When I’m training for a 50K I basically try to do a 20 mile run every weekend.

Fortunately I live in Klamath Falls, on the East side of the Cascades of Oregon, where we have relatively cold Winters and generally cool Spring and Autumn. Summer, obviously, can be pretty hot – but nothing like Southern California, Arizona, Mexico, the South, etc.

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Resting During a Trail Run

I have also noticed over the past several years that I did quite poorly during marathons if the weather got hot. The concept of hot weather is a relative term – for me anything over 70°F (21°C) would be considered hot. My ideal running weather would be 35 to 55°F. Ten years ago I could do a 20 mile run when it was 90°F (32°C) without much problem. Those days are over.

I’d be interested in hearing from other people with atrial fibrillation with respect to this. Please comment.

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Ringo – Pooped Out After a Long Trail Run