Atrial Fibrillation (AF) | Acute Management | ABCDE

geekymedics.com/management-of-acute-atrial-fibrillation/

June 18, 2018

This guide provides an overview of the recognition and immediate management ofatrial
fibrillation (using an ABCDE approach).

This guide has been created to assist students in preparing foremergency simulation sessions
as part of their training. It is not intended to be relied upon for patient care.

Tips before you begin

Treat all problems as you find them
Re-assess regularly and after every intervention to see if your management is effective
Make use of the team around you to delegate tasks where appropriate – is another clinical
member of staff available to help you?
All critically unwell patients should have continuous monitoring equipment attached for
accurate observations (e.g. blood pressure)
If you need senior input for your patient,call for help early using an appropriate SBARR
handover structure (check out the guide here)
Review results (e.g. laboratory investigations) as they become available
Make use of medical school/hospital guidelines and algorithms for managing specific
situations such as AF
Any medications or fluids will need to beprescribed
Your assessment and management should be documented in the notes (however this should
not delay clinical management)

A bit of background

What is AF?
AF is an atrial tachydysrhythmia, ‘tachy’ meaning fast and ‘dysrhythmia’ indicating chaotic and
uncoordinated electrical activity.

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In AF multiple waves of electrical activity compete with each other in the atrium and bombard the
AV node. This results in irregular conduction down the bundle of His, an irregular ventricular
rhythm and ultimately decreased cardiac output.

The causes of AF are vast and complex but usually, a patient with AF has an underlying abnormal
atrium, both anatomically (dilated) and histologically (fibrotic from inflammation).

Patients may suffer from symptoms of AF constantly or intermittently, some patients may be
completely ‘asymptomatic’ and may not even be aware that they have AF.

What is ‘fast’ AF?

Some patients present with a new-onset of AF symptoms such as rapid palpitations, breathlessness
or fluttering in the chest. You may hear some clinicians referring to this presentation as ‘fast AF’,
however, this term should be avoided because all patients with AF have rapid and chaotic atrial
activity. Instead, this presentation is AF with a rapid ventricular response (sometimes written
as AF with RVR).

If a patient experiences new or worsening AF symptoms, then it is important to thoroughly

investigate them in order to identify and treat any underlying triggering factors.

What can trigger a change in AF?

There are many conditions that can either trigger new AF or make pre-existing AF worse. TheRoyal
College of Emergency Medicine have created a useful mnemonic, PIRATES, to remember common
causes:

Pulmonary embolism
Ischaemia
Respiratory disease
Atrial enlargement or myxoma
Thyroid disease
Ethanol
Sepsis/sleep apnoea

Why is it important to learn about?

AF is very prevalent, and it is considered to be the most common sustained arrhythmia. Recent data
estimates that 0.5-1% of the general population have AF, and the frequency increases with age to
~10% in those older than 65 years. This means that you are very likely to meet and care for patients
with AF when you start work as a doctor.

In addition, patients presenting with new-onset AF may be unwell, and therefore it is important to
recognise, manage and escalate their care promptly.

Clinical features of new-onset AF

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Signs and Symptoms

Patients may report the following symptoms as a result of their arrhythmia

Palpitations
Fluttering in the chest
Dizziness
Shortness of breath
Anxiety
Chest pain

Signs you might detect include

A rapid, irregularly irregular pulse

You may also identify signs of the underlying cause of worsening AF

Bibasal crepitations on chest auscultation (heart failure)
Raised JVP (heart failure)
Tremor, sweating or neck goitre (thyroid disease)
Signs in keeping with focal infection or sepsis

Investigations
A 12 lead ECG will likely show an irregularly irregular rhythm and an absence of P waves
Routine blood tests (including TFTs) and a CXR should be performed

Initial steps
You are likely to see this patient after a brief handover from another member of staff.

Introduction
Introduce yourself to the patient
Ask the patient how they are feeling and if they have any pain
Pay attention to their ability to speak in full sentences (an inability to do this suggests
significant respiratory distress)

Inspection

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Perform a quick general inspection of the patient to get a sense of how unwell they
are:

Check consciousness level using AVPU

How do they look?
How is their breathing?
What is around the bedside? (look for cardiac monitors and ECG leads, cardiac medications,
warfarin booklets)

Preparation
Make sure the patient notes, observation chart and prescription chart are on hand (this should
not delay your immediate clinical assessment)
Ask for another clinical member of staff to assist you if possible

If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per
resuscitation guidelines.

Airway

Assessment

Can the patient talk?

YES:

Airway is patent; move on to breathing assessment

NO:

Look for signs of airway compromise (e.g. see-saw breathing, use of accessory muscles,
diminished breath sounds, added sounds)
Is the patient cyanosed?
Open the mouth and inspect: is there anything obviously compromising the airway (e.g.
secretions)?

Intervention
In any case of airway obstruction, seek immediate expert help from an anaesthetist. You may need
the crash team. In the meantime, you can perform some basic airway manoeuvres to help maintain
the airway.

Maintain the airway whilst awaiting senior input

1. Perform head tilt, chin lift manoeuvre.

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2. If noisy breathing persists try a jaw thrust.

3. If airway still appears compromised use an airway adjunct:

Insert an oropharyngeal airway (Guedel) only if unconscious (as otherwise patient may
gag/aspirate)
Alternatively, use a nasopharyngeal airway (better tolerated if the patient is partially
conscious)

Breathing

Assessment

Observations
Oxygen saturations: aim for 94-98%
Respiratory rate: tachypnoea (high respiratory rate in this context may indicate pulmonary
oedema or an underlying respiratory pathology causing hypoxemia)

Examination
Look: watch the patient breathing from the end of the bed – do they seem distressed?

Feel: check the position of the trachea – is it central?

Listen:
Auscultate the lungs to identify potential triggers of AF (e.g. pneumonia)
Assess air entry bilaterally and listen for added sounds (see our respiratory
examination guide here)
Can you hear crackles indicative of an infection or bilateral crepitations indicative of
heart failure?

Intervention
Depending on the patient’s oxygen saturations, they may require supplemental oxygen
If required, titrate to pulse oximetry saturations aiming for 94-98%

Investigations
A plain film chest radiograph is indicated for patients presenting acutely with symptomatic AF
to investigate potential precipitating illnesses such as pneumonia (see our CXR interpretation
guide)

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Circulation
It is important to establish the duration of the dysrhythmia – is it new? (this will guide
management).

Assessment

Observations
Heart rate: Tachycardia (>120 bpm) is common in symptomatic AF

Blood pressure:
Most patients with AF will be haemodynamically stable.
However a minority of patients may become haemodynamically unstable and present
with hypotension, this usually occurs in combination with prolonged periods of
tachycardia >150 bpm.
If your patient has symptomatic AF and is haemodynamically unstable,seek urgent
senior input because this may require DC cardioversion.

Capillary refill time: If the peripheral CRT is prolonged (>2 seconds), this may be a sign
that the patient is shocked secondary to inadequate left ventricular function.

Examination
Palpate radial pulses (bilaterally): an irregularly irregular pulse is characteristic of AF.
Tap out the rhythm on the table whilst palpating if you are struggling to determine whether
it’s regular or not.

Palpate apex beat: Can you feel the apex beat in the correct place or is it deviated? If the
latter, it may imply an enlarged heart and an underlying anatomical abnormality.

Auscultation: Are the heart sounds regular and is there any added sounds? (if you hear
murmurs then this may indicate underlying structural cardiac pathology)

Investigations

12 Lead ECG
This will likely show an irregularly irregular rhythm with an absence of P waves see
( our ECG
interpretation guide)

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Blood tests
Full blood count (FBC) – to assess for raised white cells (infection) and anaemia
Urea and electrolytes (U&Es) – to assess for electrolyte disturbances
C-reactive protein – to assess for evidence of infection
Thyroid function tests (TFTs) – hyperthyroidism is a potential trigger for AF
Troponin – if there is a history of recent chest pain this may be appropriate
Coagulation studies – might be relevant if the patient is already anticoagulated (e.g. INR)

Management
In order to manage AF, you must consider the following:

1. Treating any precipitating factors that may have triggered AF

2. Assessing the patient’s stroke risk and need for anticoagulation
3. Controlling the rapid heart rate
4. Controlling the symptoms of an irregular rhythm

NB: the patient may also present with unstable AF with haemodynamic instability (systolic BP
<100). Unstable AF is rare and necessitates urgent senior input. The patient will require rapid
restoration to sinus rhythm via either DC cardioversion (electrical cardioversion) or antiarrhythmic
drugs (pharmacological cardioversion) such as flecainide or amiodarone. Cardioversion should only
be performed by somebody with appropriate training, skills and experience, and it will often require
sedation and airway management by an anaesthetist. You need to keep your patient nil by mouth
from the time at which you identify they may be suitable for cardioversion.

1. Treating any precipitating factors that may have triggered AF

The majority of AF is due to underlying precipitating factors (rememberPIRATES). Often AF will
resolve to sinus rhythm when the underlying condition ‘driving’ the irregular rhythm has been
treated.

2. Stroke risk and need for anticoagulation

Patients with AF are at increased risk of stroke from atrial emboli. Long-term oral anticoagulation
with a suitable agent (direct acting oral anticoagulant or warfarin) significantly reduces this risk. The
exact risk for a particular patient can be calculated using the CHA2DS2-VASc scoring tool. The
benefit of anticoagulation needs to be considered against the risk of a patient having a significant
bleed due to anticoagulation, which can be calculated using the HAS-BLED score. Immediate
anticoagulation can be achieved with a treatment dose of subcutaneous low molecular weight
heparin.

3. Controlling the rapid heart rate

In new-onset AF with rapid ventricular response patients often need heart rate control. For acute
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rate control, beta-blockers and diltiazem/verapamil are preferred over digoxin because of their rapid
onset of action. The choice of drug and target heart rate will depend on patient characteristics (see
below). Generally, cardiac output is sufficiently optimised by maintaining a heart rate of <110 bpm
at rest. More than one drug may be required. If heart rate cannot be controlled to <110 bpm in the
acute setting patients may require admission under a medical team for further rate controlling
therapies.

Left ventricular ejection fraction (LVEF) < 40% OR signs of congestive heart failure

First line:

The smallest dose of beta-blocker to achieve rate control:

Amiodarone is an option in patients with haemodynamic instability or severely reduced
LVEF
Initial resting heart rate target < 110 BPM

Second line:

Add digoxin (initial resting heart rate target < 110 BPM)

Left ventricular ejection fraction (LVEF) ≥ 40%

First line:

Beta-blocker OR Diltiazem OR Verapamil

Check previous drug history to avoid concomitant administration
Initial resting heart rate target < 110 BPM

Second line:

Add digoxin (initial resting heart rate target < 110 BPM)

Further management principles following initial rate control

Avoid bradycardia
Perform echocardiogram to determine further management/choice of maintenance therapy
Consider the need for anticoagulation

4. Controlling the symptoms of an irregular rhythm

Rhythm control therapy is indicated to improve symptoms in patients who remain symptomatic on
adequate rate control therapy. It has not been shown to improve long-term outcomes. Rhythm
control is generally not indicated in the acute setting unless the patient is unstable. Long-term
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maintenance of sinus rhythm may be achieved using medications, DC cardioversion or cardiac
ablation therapies.

Disability

Assessment
Temperature: If higher or lower than normal parameters, consider infection as a cause
Assess level of consciousness using AVPU or GCS
Check blood glucose: 4.0 – 11.0 mmol/L is normal

Exposure
The ‘everything else’ part of your assessment will involve exposing the patient to perform a thorough
general inspection.

Look for:

Peripheral oedema (heart failure)

Swollen tender calf (deep vein thrombosis)

Reassess ABCDE
It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows
continual reassessment of the response to treatment and early recognition of deterioration.

If the patient does not respond to treatment or deteriorates, critical care input should be involved as
soon as possible.

Next steps
Well done! You’ve stabilised the patient and they’re doing much better. Just a few more things to
do…

Take a history
Take a more detailed history of what has happened and how the patient has been. Involve staff or
family members as appropriate.

Check out our history taking guides here

Review

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Review the patient’s notes, observations, fluid charts, and any investigation findings. Double check
the medications you have just prescribed, and any routine medications the patient is taking.

Document
Document your ABCDE assessment clearly, including examination, observations, investigations,
interventions, and patient response/changing condition. Write down any pertinent details from your
history-taking.

See documentation guide

Discuss with seniors

If a senior doctor hasn’t already been involved, it is important to contact them and make them aware
of the unwell patient. As a junior doctor, it would be appropriate to give an SBARR handover
outlining your assessment and actions, and to discuss the following:

Are any further assessments or interventions required?

Does the patient need a referral to HDU/ICU?
Should they be referred for a review by a speciality doctor?
Should any changes be implemented to the management of any underlying conditions?

Handover
The next team of doctors on shift should be made aware of any patient in their department who has
become acutely unwell.

Further reading
https://www.rcemlearning.co.uk/references/atrial-fibrillation/

https://www.nice.org.uk/guidance/cg180

https://www.escardio.org/

References

1. ESC Guidelines for the management of atrial

brillation developed in collaboration with
EACTS. European Heart Journal. Published 2016.

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Editor

Andrew Gowland

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