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Stable Afib in the Ed

A 55M h/o HTN presents with 5 hours of palpitations that woke him from sleep.
His complaint is that the sensation of his fast beating heart is uncomfortable. There is no chest pain, no SOB.
There are no other associated symptoms.

Vitals: HR 145 BP 120/65 RR 12 T98.0 98%
Patient is well appearing, exam unremarkable other than a tachy radial pulse.
EKG shows atrial fibrillation with RVR.
Routine ancillary ED studies are performed to investigate possible etiologies of his Afib.

(How) do you want to manage his stable afib?
Specifically, do you want to perform electric cardioversion, chemical cardioversion, chemical rate control, or sit on hands and admit/obs?

There is not consensus on the optimal treatment of a patient with stable, presumed new-onset afib in the ED.

Why do we address afib at all? The Framingham data inform us that in chronic afib the risk of stroke is increased by 5 fold, and the risk of death is doubled. Further, a rapid ventricular rate often results in symptoms such as chest discomfort and reduced exercise tolerance that decreases quality of life. For some time, management of new-onset afib in hospitals or clinic was generally directed towards rhythm control, using oral anti-arrhythmics such as amiodarone, sotalol, propafenone etc. to maintain a sinus rhythm.

The AFFIRM trial (4060 patients, 2002) randomized patients into two groups, either a rate control (<80-110 BPM) or a rhythm control strategy, and found that rate control was not inferior in outcome of death or quality of life, and resulted in fewer hospitalizations and medication adverse effects. The smaller RACE trial (522 patients, 2002) demonstrated similar results. Subsequently, management of Afib in the US, whether inpatient, outpatient, or ED, has trended towards rate control with antiplatelet or anticoagulation therapy as needed per risk stratification. Rate control is usually achieved with betablockers or nondihydropyridine calcium channel blockers (verapamil or diltiazem).


There is not data to suggest that new onset (<48hr) atrial fibrillation with RVR in an otherwise hemodynamically stable patient is itself an immediately dangerous condition requiring emergent action. Benefits of early cardioversion are that cardioversion is more successful when performed <48 hours, and may save the patient time, money and provide earlier symptom relief. The feared complication of cardioversion in afib is a thromboembolic event with end organ damage, namely, stroke. There is a 0.8% risk of stroke after cardioversion in a patient not on chronic anticoagulation (patient described in vignette). For those on therapeutic anticoagulation for h/o afib with paroxysmal conversion to afib, the risk is 2%. Even if cardioversion is successful and the person is in sinus rythym, the patient remains at increased risk of thromboembolism for up to 4 weeks due to the delayed return of strong, organized atrial contraction.

Several small studies have examined ED afib protocols, including early ED cardioversion, and the results and discussions seemingly support early cardioversion, however they are limited by extent of followup, and small sample size.

Of note, often in paroxysmal afib the heart will revert to sinus rhythm without any intervention, this occurs in up to 27% of patients who were observed for 7 hours in one study.

The AHA/ACC outlines 3 objectives for stable afib management: 1) rate control, 2) prevention of thromboembolism, and 3) correction of rhythm disturbance. However these are not guidelines specific for acute afib episodes, and thus are not literal guidelines for ED management.

If the ED physician does not feel compelled to perform cardioversion in stable afib due to the concern for immediate or delayed thromboembolic event, risks of procedural sedation, or lack of immediate medical benefit to electrocuting someone with stable vital signs, there seems to be a generally accepted ED pathway for stable new-onset afib:

1) Treat symptoms via rate control
2) Admit or place in obs unit for echo and initiation of anticoagulation with cardiology consult for possible planned cardioversion.

Interestingly, rates of ED intervention and discharge of patients with afib are much higher in Canada compared to the US; proposed contributing factors are differences in comorbid diagnoses, availability of prompt followup, and a different medicolegal environment.


Alden J. McDonald, Andrea J. Pelletier, Patrick T. Ellinor, Carlos A. Camargo Jr., Increasing US Emergency Department Visit Rates and Subsequent Hospital Admissions for Atrial Fibrillation from 1993 to 2004, Annals of Emergency Medicine, Volume 51, Issue 1, January 2008, Pages 58-65

Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation. 1998 Sep 8;98(10):946-52.

Ian G. Stiell, Catherine M. Clement, Robert J. Brison, Brian H. Rowe, Bjug Borgundvaag, Trevor Langhan, Eddy Lang, Kirk Magee, Rob Stenstrom, Jeffrey J. Perry, David Birnie, George A. Wells, Variation in Management of Recent-Onset Atrial Fibrillation and Flutter Among Academic Hospital Emergency Departments, Annals of Emergency Medicine, Volume 57, Issue 1, January 2011, Pages 13-21,

Ian G. Stiell, David Birnie, Managing Recent-Onset Atrial Fibrillation in the Emergency Department, Annals of Emergency Medicine, Volume 57, Issue 1, January 2011, Pages 31-32, I

Russo V, Navarin S, Zampini G, Magrini L, Mann C, et al.
Management of atrial fibrillation in the Emergency Department: current approach and future expectations. Eur Rev Med Pharmacol Sci. 2013 Dec;17(23):3132-47

Rodney H. Falk, Controversies in Cardiovascular Medicine: Rate Control Is Preferable to Rhythm Control in the Majority of Patients With Atrial FibrillationCirculation 2005; 111: 3141-3150

Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ; Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control and rhythm control in patients with recurrent
persistent atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1834-40.

Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD; Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1825-33

Ultrasound is Your Friend

Pt is 54 yo M with PMH of DM, HTN, Crohn Disease presents with 2 days of worsening vomiting, had diarrhea initially that has now stopped and is no longer passing gas, also reports some slight abdominal distention. Patient has had several abdominal surgeries in the past, denies any fevers, any blood in the vomit or diarrhea, no travel. An abdominal exam reveals a soft, slightly tympanic, diffuse moderate tenderness. Pt is afebrile and normotensive. You have a strong suspicion for a small bowel obstruction and place the order to put the patient for CT, however, there’s been difficulty getting people to CT in a timely fashion all day so your attending suggests getting an abdominal xray to expedite diagnosis. How good is the abdominal xray at diagnosing small bowel obstruction and what other imaging modalities do we have at our disposal?

Continue reading “Ultrasound is Your Friend” »


Patient is 49 yo F who presents to ED with few days of fever (T max 102F), progressive headache, neck stiffness. Patient denies any travel, rashes, sick contacts. Pt complains she can’t be in a well lit room or go outside without pain. You have a high suspicion for meningitis and so perform an LP.

CSF shows as follows:

WBC 100/mm3 (60% N, 35%L)

Protein 100

Glucose 40 (serum glucose 100)


Aside from a gram stain and culture, are there any other tools to help differentiate between viral and bacterial meningitis?

Continue reading “Meningitis” »

Sbp Pearls

Pt is 58 yo M with PMH of alcoholism, HCV with liver cirrhosis (h/o variceal GI bleeds, h/o SBP, h/o hepatic encephalopathy) presents to ED with 2-3 days of altered mental status and fever, you want to rule-out Spontaneous Bacterial Peritonitis and you send your newly minted intern over to get set up for a paracentesis and before you know-it, the intern is back, smiling brightly, with a vial of presumed ascitic fluid, although looking pretty bloody.


You do a quick check to make sure the patient is not hemorrhaging in the hall and then you get a call from the lab reporting a panic value of an INR of 2.2. How do you correct for a bloody paracentesis to get an accurate PMN count in order to diagnose SBP? Was there any contraindication to doing paracentesis in a person with INR 2.2?


Correction for a bloody tap: Continue reading “Sbp Pearls” »

Biphasic Reactions with Anaphylaxis?

“Incidence of Clinically Important Biphasic Reactions in Emergency Department Patients wit Allergic Reactions or Anaphylaxis”

Grunau BE, Li J, Yi TW, et al.

Annals of Emergency Medicine 2014; 63(6): 736-744


Background: Allergic or anaphylactic reactions are fairly common presentations to the ED.  After initial treatment and clinical improvement, a proportion of patients may develop a second “biphasic” reaction, which may actually be more severe than the initial presentation.  Because of this concern, patients are often held for observation for 6 or more hours.  This prolonged ED stay has not been shown to decrease biphasic reactions’ complications, yet incurs significant costs.  The goal of this study was to examine the incidence of clinically important biphasic reactions.

Methods: Chart review performed on data from 2 urban EDs, collected on adult patients presenting during a 5-yer period with “anaphylaxis” or “allergic reaction.”  Primary outcome was the proportion of patients with a clinically important biphasic reaction, secondary outcome was mortality.

Results: Of 428,634 ED visits, 2819 encounters (496 anaphylactic, 2323 allergic reactions) were reviewed.  185 patients had at least 1 subsequent visit for allergic symptoms.  5 clinically important biphasic reactions were identified (0.18%, 95% CI 0.07-0.44%); 2 occurred during the ED visit, and 3 were post-discharge.  2 patients with the biphasic reaction were in the anaphylaxis group (0.40%), and 3 were from the allergic reaction group (0.13%).  There were no fatalities.

Conclusion:  Clinically important biphasic reactions and fatalities were rare in ED patients presenting with allergic or anaphylactic reactions.  This study’s results suggest that it may not be necessary to conduct routine prolonged monitoring of patients whose symptoms have improved after initial treatment.

Jeremy Faust