Tachycardia in a Patient with Atrial Fibrillation

Vital Signs

• Temperature: 98 °F, axillary

• Blood pressure: 159/89 mmHg

• Pulse: 160 beats per min (bpm) - narrow complex, irregular rhythm on telemetry ( Fig. 4.1 )

  

• Respiratory rate: 22 breaths per min

• Pulse oximetry: 95% oxygen saturation on room air

Focused Physical Exam

The patient was a middle-aged male in mild distress. Appropriate personal protective equipment was established, and the patient was examined. The patient was alert and oriented. He reported having an uncomfortable, fluttery feeling in his chest. He also complained of dizziness even while lying flat. However, he denied any overt chest pain. His cardiac exam showed tachycardia with an irregular rhythm. Jugular venous distension was not appreciated, and no peripheral edema was present. Lung and abdominal exams were benign.

Interventions

A cardiac monitor and pads were attached immediately. The monitor showed narrow complex tachycardia with irregularly spaced complexes and a rate variability between 140 to 180 beats per min. Stat electrocardiogram (EKG) was obtained, which was notable for the absence of p waves. The patient was given 5 mg intravenous (IV) metoprolol push which did not decrease the heart rate. The patient’s blood pressure fell to 110/83 mmHg, and a 500cc fluid bolus was initiated. He was given another 5 mg of IV metoprolol which again did not affect the heart rate. Then, 10 mg IV of diltiazem was given, which decreased the heart to a range of 120-130 beats per min. The patient was started on a continuous diltiazem drip and moved to the stepdown unit. Stat electrolyte panel, magnesium level, troponin level, and complete blood count were ordered, which were unremarkable. Given his recent history of hemorrhagic stroke, anticoagulation was not initiated.