Is it appropriate to treat a patient in a fast uncontrolled a-fib who is experiencing cardiac ischemia type pain under the cardiac ischemia protocol? OR is it more appropriate to withhold treatment assuming this pain is rate related.
If, based on the information provided on scene, it is determined the chest pain to be rate related (in this case tachydysrhythmia), your care goal becomes the management of that rate. Should you conclude the pain is ischemic in nature or that the patient still experiences chest discomfort after the management of the rate and suspect cardiac ischemia, considering ASA and Nitro administration is reasonable.
Administering nitro in the presence of atrial fibrillation increases the risks for an adverse reaction such as hemodynamic instability where you would notice a fall in cardiac output (ex: fall in blood pressure, pulmonary congestion).
Different factors can contribute to the adverse hemodynamic changes and can be used to assess the risk in administering nitro in the presence atrial fibrillation such as:
• Nitro decreases the preload
• Many patients with atrial fibrillation develop a modest decline in left ventricular performance
• Heart Rate – too fast or too slow
• Loss of atrial systole required for optimal ventricular filling
• Increased mitral regurgitation
The following factors can also be assessed to assist with your decision-making process:
Note that consulting with a Base Hospital Physician and deciding together what the best and safest course of action would be for your patient is an option.
Please ensure information, clinical picture, pertinent +/- and rationale supporting your management plan are documented.