Thanks for all of your comments and plans. Lots of good ideas – wish I had thought of a few of them!
So here is how I managed the man with severe COPD, ?AF and severe AS:
- NIV – BiPaP, started ASAP with a lowish pressure settings and wound it up as long as the BP / conscious level allowed
- Phenylepherine infusion – a 200 mcg bolus, then infused and repeated the bolus. Try to keep the BP up and hopefully induce a reflex bradycardia?
- No DC cardioversion – the man was too awake to shock, and I was too scared to give him any sedation that might have knocked off his respiratory drive. In my head – there is no way I could do as good a job with ventilation as he was doing. Even a minute or two of sedation would have left us in dire straights with his resp. failure crashing quickly.
- IV bolus of Amiodarone 300 mg – aim to get back to SR or at least some B-blockade / slowing.
And almost like magic after about half the amiodarone was in and as the 2nd phenyl epherine bolus went in – he flipped into SR at ~110/min. He turned pink and felt a lot better – he was still puffing away, but happier! I am not sure which drug or God did the trick – but it worked – good enough for me!
After this we loaded with some broad lung ABs and steroids. we gave IV MgSO4 to ward off a return of whatever SV tachyarrthmia was there intitially.
In terms of palliation vs. intubation – we have the unique scenario of being a long way from and ICU – so you decision-making here is sharpened – you have to decide on this early. Personally, in this type of case I think a good trial of NIV with medical optimisation either works or it doesn’t – if the patient does not respond I think the prospect of intubation and the week – months of ventilator-dependency that follows is not a good way to die.
It can be tricky to have “the chat” in such extreme poor situations – and I am always disappointed that the doctors who care for these chronic problems do not discuss these very real and inevitable scenarios with the patients before – when they are ‘well’ and in a better place to decide how they feel about palliation as an option. Making a patient NFR in the middle of a crisis is not the way to go – good palliation should begin much earlier!
My 2 cents. Casey
Oh, I found this article from J Emerg Trauma Shock. 2010
on treating tachyarrythmias – has a flow diagram that seems to lead to DC cardioversion in all groups!