atrial-fibrilation

First Do No Harm

Estimated reading time: Less that or equal to 5 minutes. Story Source. This story is not necessarily scary. 

As doctors, we can’t help patients who won’t help themselves. Like my patient, Maisy Leland. She has a condition known as atrial fibrillation, meaning her heart rhythms are irregular in a way that could induce blood clots. Left untreated, she could stroke out at any second. That’s why I’ve prescribed her with warfarin, a blood thinner that makes her less prone to clotting.

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Alcohol-induced dilated cardiomyopathy

Note the enlarged ventricular chambers - the increased size causes the appearance of thinned ventricular walls. Assumption that there is decreased musculature in heart walls can cause incorrect diagnosis of cause-of-death.

Dilated cardiomyopathy can cause systolic dysfunction and atrial fibrilation, as well as being a source of thromboembolism.

I don't often get terribly personal on here,

but I’ve got an appointment with my cardiologist today. As some may know, I have a heart condition that fluctuates between inconvenience and hospitalization. Over about the last two weeks, I’ve taken a turn for the not so good. I’m not dying, by any means, but I’m not at all comfortable and, though this heart thing doesn’t usually bother me, I’m starting to get a little scared.

There’s a terribly simple surgical fix for what I have, but for reasons that are probably pretty obvious in America’s current political climate, I am not covered under my wife’s medical insurance. Today I’m going to talk with my doctor, and his staff, about trying to do something about this even without insurance.

So, if you wouldn’t mind, I’d appreciate any and all good juju, thoughts, and energy you have. I wouldn’t usually ask, as I like to keep things light, but today is a heavy day.

Thanks, friends.

I never really appreciated the life I was given until last night while caring for a geriatric patient who was undergoing atrial fibrilation. He was straining himself with every breath and with every breath came slight chest pains. He was tachycardic and there wasn’t much I could do for him as an EMT who’s still in training. To be honest there isn’t much a professional EMT can do in this case other than supply him with oxygen, which we did through the nasal cannula he was already receiving o2 from. I stood back and watched the paramedic and his assigned EMT assess the patient. As the two collected information about past medical history, medications, allergies, last oral intake etc. I couldn’t help but to observe their living conditions. As an EMT student we are taught to take note of their surroundings especially if we are dealing with the elderly. I spotted no lighting in this man’s room. We were holding flashlights. The walls were falling apart, the wooded construction of the home was clearly visible, floors were creaking, the stairs were unstable, and the poor man was pretty much living in the left over space of the kitchen. This wwas a home for not just him but for three other people. I mean I’m thankful that it was as organized as could be, but actually seeing this kind of slum was almost negatively breath taking. I was at a loss for words completely. Just shocked. I’m always hearing news about the millions who fall under the poverty line but I had no idea that what the reporters always talk about happens not even an hour away from my area. I mean this just struck a nerve. I don’t even want to be in the medical field for the money. I want to be in it to help those who are iin need of medical assistance. This is probably very naive of me to say but I would have loved to pay for his medical bill. He had already been in the hospital that day and not even 24 hours later did he have to go back to the ER. Id want to pay for Not.only him but anyone who needs financial aid. This is a wild dream i have. I wont be making nearly wnough money to pay for everyones medical bills but… Its so sad to see people live in these kinds of conditions when I live such a wonderful life. some may say they did it to themselves, and that statement isn’t false but shouldn’t it also be our duty to help those in need and not degrade them for not trying hard enough in life? What I took from this experience was how happy and content this family seemed. They literally appreciate life so much more than I do on any given day and it was encouraging and eye opening to see what happiness is all about, what it *should* be about.

Medical Mnemonics// Causes of atrial fibrillation (characterised by absent P waves on an ECG) can be remembered using the mnemonic PIRATES.

If you like my posts, please consider taking the time to visit toho-medblr.com on your desktop and clicking on the ads, I’ve recently installed google adsense. It feels a bit cheeky, but means you’ll be seeing more original content on this blog.

https://www.gofundme.com/5mphd9h4 This is my dad Steve Craig. He is 46 years old. He’s always been a hard working man, but recent events have left him unable to work. On October 8th, he went to step up on a ladder, the safety malfunctioned on his nail gun, resulting in a 3 ½ inch nail going through the left side of his brain into the right side. The nail was removed, and he seemed alright in the sense that he wasn’t paralyzed and retained his memories. All of the stress from the event and the craniotomy brought our attention to the fact that he has a heart condition called Atrial Fibrillation (a fib). After his surgery they gave him powerful antibiotics, which ended up killing all of his good gut bacteria, and he had a painful fight with c diff. We were finally able to get him on insurance, and he was able to get a referral to a cardiologist. They came up with a plan for medications, and procedures to get his heart back to normal. They were concerned that he might throw a clot, so they put him on blood thinners. He threw a clot anyway, which resulted in him suffering a mini stroke, on January 17th. He was able to regain his speech, and the ability to move his right side for the most part. He has not regained proper taste, or full sensation of his right side. He has not been able to work since October, and went in search of something to bring in some money. He found work splitting wood. Due to his irregular heartbeat causing him poor circulation in his extremities, and the loss of sensation from the stroke, he unknowingly overexposed himself to the cold. When he finished for the day and removed his glove he discovered he had frostbite on his right hand. He has been seen in Iowa City, and they are optimistic that he will be able to avoid amputation. However, he still has many appointments to attend for his heart and his frostbite. I have been doing as much as I can to help him, but I am a full time student and single mother with very limited resources. We struggle to meet the financial needs of his medical treatments including things like paying for prescriptions that are necessary but not covered by insurance, reaching the allowed 4 prescriptions per month then having to pay full price out of pocket, and gas to make the trips to Freeport, Rockford, or Iowa City based on who has the proper resources to help him throughout the different medical problems he faces. Due to the financial strain, he has also been struggling with proper housing. If you are able to help by donating or sharing this link, we would be forever appreciative of your kindness. Thank you very much.

(thanks to my sister @–buttslut for writing this all :+) if you cant donate please reblog this just to signal boost) ((also there are pictures of his injuries on the gofundme page so like. just a warning))

youtube

DC Cardioversion - saw this today on a patient with persistent AF, we used 300J and he jumped off the bed a bit more than this guy.

Atrial fibrillation is an irregular heart rate that increases your risk of stroke, heart failure and other heart related complications. This is the most common abnormal heart rhythm. During atrial fibrillation, electrical impulses are triggered from many areas in and around the atria rather than just one area.

www.learninghumananatomy.com

An update for those interested:

The cardiologist appointment went well. My doctor was pretty adamant about getting me into surgery as soon as possible, so his people are going to work with my parent’s insurance to see if they can get me covered. I should know in about a week, and then we can get to scheduling surgery.

And, in also happy news, I got the library job! I’ll be the weekend nightshift circulation desk supervisor for our local private college. Not much of a social life, but, you know, I really don’t care. I WORK IN A LIBRARY. (And a damn snooty one at that.)

Heparin is widely used as an injectable anticoagulant. (It can also be used to form an inner anticoagulant surface on various experimental and medical devices such as test tubes and renal dialysis machines.)

Heparin is a naturally occurring anticoagulant produced by basophils and mast cells. Heparin acts as an anticoagulant, preventing the formation of clots and extension of existing clots within the blood. While heparin does not break down clots that have already formed (unlike tissue plasminogen activator), it allows the body’s natural clot lysis mechanisms to work normally to break down clots that have formed.

Heparin is generally used for anticoagulation for the following conditions:

  • Acute coronary syndrome (e.g., NSTEMI)
  • Atrial fibrillation
  • Deep-vein thrombosis and pulmonary embolism
  • Cardiopulmonary bypass for heart surgery
  • ECMO circuit for extracorporeal life support
  • Hemofiltration
  • Indwelling central or peripheral venous catheters
Management of Atrial Fibrillation (AF)

There are two main aims in the management of AF:

  • Control ventricular rate, or attempt to restore sinus rhythm
  • Assess for risk of stroke and thromboemobolism

Acute Management

If haemodynamically unstable –>

  • DC cardioversion
  • If known permanent AF –> Beta Blockers, Verapamil or Amiodarone

If non-life threatening, alternative is IV Amiodarone (300mg, IV central line, 60 mins), or Flecainide, which is preferred in WPW syndrome.

NB, flecainide should be avoided in Ischaemic Heart Disease, or Left Ventricle Dysfunction

If urgent ventricular rate control is needed - Beta Blocker, Verapamil, or Amiodarone can be give IV.

If haemodynamically stable –> different management

Restoration of of sinus rhythm

If onset of AF definitely <48 hours, administer Heparin, then:

  • DC cardioversion or
  • IV  or oral cardioversion with flecainide, amiodarone
  • No need for anticoagulation if definitely <48 hours since onset

If onset of AF >48 hours

  1. Anticoagulate for at least 3 weeks (if this is not possible use LMWH, and rule out atrial left thrombus)
  2. Electrical cardioversion preferred to IV
  3. Anti-coagulate for at least 4 weeks, and assess long term risk - follow up at 1 month
  • Success of procedure can be increased by 4 weeks of oral sotalol or amiodarone

Chronic Management

AF can be caused by non-cardiac events such as pneumonia, so this step is only necessary in cases where such a precipitating factor exists.

Maintenance of sinus rhythm

  1. Beta blocker
  2. Flecainide, propafenone or Sotalol (preferred with CAD)
  3. Amiodarone
  4. If rhythm control has failed –> Rate Control

Rate Control - for Persistent/Permenant AF

  1. Beta-Blocker or Verapamil
  2. If more rate control needed:
  • During exercise - Verapamil and Digoxin
  • At rest - Beta blocker or Verapamil, and Digoxin

If further control needed refer –> Cardiologist

Thromboembolism Risk

As with most risk assessment, there’s a calculation (and tool) for it. The CHA2DS2VASc (Link) score predicts the yearly risk of a thrombotic stroke in patients with AF. It can be used to stratify patients into groups to guide whether the anticoagulation, or anti-platelet medication is indicated.

Heart flutter

Painful. Not happy happy heart flutter. Been happening the past two days and I keep dreaming that I’m unable to breath or someone is squeezing me reaaaaaaly hard. Ouch >.<. They do say that sleeping on your left side can cause some pressure on your chest and restrict blood flow thus leading to bad dreams. Hmmmm. But in waking life it’s a little freaky. As if any moment I’ll become an old woman and ahhh ohhhh owwww ahhh. passes out >.<

Hearts all around

I’m rewatching the episode right now but I needed to pause to talk about this thing.

Harold had just had heart replacement(correction here) surgery, Arthur had “a broken heart” and they assumed Mildred would be the next one because of her atrial fibrilation. What all those have in common is that their vulnerability was their heart, so why was Dean vulnerable then?

Because of matters of the heart of course. There is an extraneous force calling for his heart, making him feel an attraction that scares him and that he doesn’t want. And when he confided this on someone close to his heart, he was told that it may be a good thing they could use to their advantage, instead of receiving the support and understanding he expected. There’s also the fact that unbeknownst to him he just confesed all his intimate fears to an enemy who will no doubt take advantage of that knowledge and unscrupulously use it to further his own goals. There is our Dean’s very vulnerable heart at the moment.

It’s also interesting to see how he was paralleled to the other three vulnerable hearted people this episode.

Stealing Harold’s viagra (just like he had stolen it from other people before) is yet another symbolic nod to Dean getting old. When Dean says “Maybe we oughta make a reservation” when they’re arriving to the retirement home, the camera very blatantly pans down to focus on the picture of the old happy couple staring out at the sea.

Arthur’s broken heart is due to his emoji-loving wife having just left him, and not returning his calls. He also would like to have sent her the heart, tell her how he really feels, but he can’t help being rougher than that to her. Now, I don’t know why, but this kinda reminds me of someone who has just left and isn’t giving any signs of life, and who Dean has some trouble showing his appreciation to¿? I’m just saying, maybe Cas said yes because Dean keeps sending poop emojis when actually he meant to send the heart.

[gif source]

And then we have Mildred, who told him to follow his heart, and was able to see that there’s someone else he’s pining for.

Now, knowing all those very interesting things about Dean’s heart, I would say his vulnerablity is as much about Amara as it is about his pining for Cas and his worry for whatever is going on with him, and even in a foreboding sense, the fact that he exposed his heart to a dangerous enemy and he doesn’t even know it yet.