I feel like my heart is skipping a beat…

Hello all and welcome to the next blog from @ededucate and this one is all about Atrial Fibrillation AF or Fast Atrial Fibrillation F(AF), something we see quite a lot of in ED. The nursing considerations in these patients are important and in the last few months I have been involved in a couple of more tricky cases of F(AF) that I wanted to share with you. This blog is not the full picture of AF from an A&P point of view (however I am going to link some awesome resources where you can delve deeper into this subject at the end), this blog is about the ED nursing responsibilities in looking after these patients. 

What is AF? 

An Atrial tachydysrhythmia commonly characterised as an irregularly irregular pulse or on the ECG the absence of P waves before each QRS or the printed ECG say ‘Atrial Fibrillation’ at the top (NOT).

AF is split into three classifications [1]:

Paroxysmal AF – Terminates spontaneously and most within 48 hours

Persistent AF – Seven days or more or is terminated by cardioversion

Permanent AF – Cardioversion not attempted or not terminated by cardioversion

For more on the learning around AF see the RCEM Learning module which is open access and you can learn more about this condition.

This is a really common condition and something you will see on a large proportion of patients you look after each day, but there is a difference between the patients who have AF as a condition and live with it and those who are admitted to ED because of AF or F(AF) or a complication of having AF. 

*Learning stop point*

What does it mean for your circulation system when you have AF, and your circulation assessment (stop here and have a think about this one then come back to the blog. (Keep notes on this and use it to form a reflection and get your RCN Framework signed off by your education team). 

Thoughts…

Having AF makes you more likely to clot- hence patients with permanent AF are very often on blood thinning medication such as warfarin or apixaban- this changes as they get more frail as the decision to be on a blood thinner is balanced against the risk of falls, how many patients do we see that have to be CT’d on a fairly regular basis because they have fallen on blood thinners. 

Having AF makes your circulation more compromised and these patients are often difficult to get a blood pressure on using the electronic machines so it may say ‘cuff timeout’ more often and manual BP’s may be your best course of action. 

Anyone in Fast AF should be attached to full ED monitoring including regular BP cycling regularly, 3 lead ECG and SPO2. 

It stands to reason of course that these patients should DEFINITELY be undressed, please don’t be that nurse who has this patient on full monitoring, with their sleeve rolled up to show the green cannula and the wires all around the their clothes!!! (Stop ranting Ash….. ok ok)

Case Study

Bob ( obviously anonymised but loosely based on a real patient) is a 49 year old male who is in the ED Resus bay having booked in feeling unwell and an ecg picked up fast AF. I clicked on this patient as the ACP having just started my shift. 

After taking a brief history I found that Bob was in fast AF and there was no clear onset time, in fact he may well have been in AF for up to three weeks as he felt unwell for that length of time. However he was haemodynamically stable and I was fairly relaxed, thinking about my next steps;

Review his bloods

Review his chest X-ray

Think about treatment strategies 

Globally this comes down to Rate control or Rhythm Control 

So are we doing something to slow the rate down or doing something to cardiovert the rhythm to sinus and this can be chemically or electrically. 

There will be a clinical guideline in your department that looks something like this

This is from the RCEM website and this particular one is from Barts Health (2014) and has now been supra-ceded by this NICE guideline [2]. Most will look similar so go and find yours and have a read. Now back to Bob…. 

As I’m sure you are already predicting- Bob is not a candidate for Rhythm control as he has been in AF for an indeterminate amount of time… the first step for these patients is to treat any obvious cause (such as infection/electrolyte abnormalities etc) and normally we would try some simple intravenous fluids in the first hour. I looked up and saw that Bob in fact had some fluids already running and thought great but when I took a closer look it was in fact Amiodarone!!! My jaw dropped and I felt a bit queasy… why??? 

Have a few minutes to think….

We have a chap with up to three weeks of AF and blood that has to be presumed to be very pro thrombotic (clotty) and he has not been on any blood thinners, the reason not to go for rhythm control here is that the risk of VTE/CVE is pretty significant. I immediately prescribed some treatment dose clexane and set about investigating why someone had chosen to prescribe a rhythm control rather than a rate control. The imposter in me started thinking…maybe I’ve got this wrong… maybe one of my senior colleagues has done this and how will I ask why?  On questioning it transpired the doctor who prescribed this had been asked to do so by the nurse looking after the patient who genuinely thought this was the right treatment as they had previously seen this drug used for the treatment of AF- hence this blog.

Nurses in ED you should know about the treatment algorithms for some of the common presenting complaints so that you can do the best for your patients however there is a limit to what you ask for your patient when someone hasn’t seen them.  I must say no harm came to Bob but the near miss was very real, asking someone to prescribe something without seeing the patient is bad practice and a big risk to all involved. Feel free to print the guideline and place it under the clinicians nose and ask them to come and review the patient but be careful of making decisions that influence patient care without the whole picture. 

AF is common and can be both straight forward and not so much- Stay tuned for the next part to this blog on a case where AF doesn’t really follow the rules and a revision of the ALS Tachycardia Algorithm.

Things to do;

Have a look at;

  • The RCEM Learning session
  • Your local guideline 

Have a think about;

  • How you have and are going to manage these patients from a nursing point of view
  • The common drugs that your local guidance recommends and ensure you are happy drawing them up.

Then wait excitedly for the next instalment of #AFGate 

Bye for now

Ash 

RCN Competency CD 1.2

References

  1. RCEM Learning (2019). Atrial Fibrillation Learning Session [Online].
  2. Atrial Fibrillation- Clinical Guideline [Online].

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