11/13/24, 7\:36 PM Guide | Atrial fibrillation (AF)
Atrial
Table of contents
Introduction
This guide provides an overview of the recognition and immediate management of atrial
ABCDE approach.
The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working
through the following steps\:
Airway
Breathing
Circulation
Disability
Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed
as they are identi
This guide has been created to assist students in preparing for emergency simulation sessions as part of their training, it is not
intended to be relied upon for patient care.
Background
What is atrial
Atrial
electrical activity.
‘tachy’ meaning fast and ‘dysrhythmia’ indicating chaotic and uncoordinated
In AF, multiple waves of electrical activity compete with each other in the atrium and bombard the atrioventricular node. This
results in irregular conduction down the bundle of His and as a result, irregular ventricular contraction. If the ventricular
response is rapid, cardiac output can become impaired due to uncoordinated myocardial contraction.
The causes of AF are vast and complex but usually, a patient with AF has an underlying abnormal atrium, both anatomically
(dilated) and histologically (
Patients may su
What is 'fast AF'?
Some patients present with sudden onset of palpitations and breathlessness and are found to be tachycardic in atrial
, 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).
Triggers for AF
There are many conditions that can either trigger the Royal College
of Emergency Medicine has created the PIRATES mnemonic to make memorising AF triggers a little easier\:
Pulmonary embolism
Ischaemia
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Respiratory disease
Atrial enlargement or myxoma
Thyroid disease
Ethanol
Sepsis/sleep apnoea
Clinical features
Symptoms
Typical symptoms of new-onset AF include\:
Palpitations (e.g. a sense of
Dizziness
Shortness of breath
Anxiety
Chest pain
Clinical signs
Typical clinical signs of AF include\:
An irregularly irregular pulse
Tachycardia (if AF with rapid ventricular response)
Tips before you begin
General tips for applying an ABCDE approach in an emergency setting include\:
Treat all problems as you discover them.
Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
Make use of the team around you by delegating tasks where appropriate.
All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
Clearly communicate how often would you like the patient’s observations relayed to you by other sta
If you require senior input, call for help early using an appropriate SBARR handover structure.
Review results as they become available (e.g. laboratory investigations).
Make use of your local guidelines and algorithms in managing speci
Any medications or will need to be prescribed at the time (in some cases you may be able to delegate this to another
member of sta
Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical
assessment, investigations and interventions.
Initial steps
Acute scenarios typically begin with a brief handover from a member of the nursing sta
name, age, background and the reason the review has been requested.
You may be asked to review a patient with AF due to palpitations, chest pain and/or dizziness.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient including your name and role.
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Ask how the patient is feeling as this may provide some useful information about their current symptoms.
Preparation
Make sure the patient’s notes, observation chart and prescription chart are easily accessible.
Ask for another clinical member of sta
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Airway
Clinical assessment
Can the patient talk?
Yes\: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No\:
Look for signs of airway compromise\: these include cyanosis, see-saw breathing, use of accessory muscles, diminished
breath sounds and added sounds.
Open the mouth and inspect\: look for anything obstructing the airway such as secretions or a foreign object.
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the
emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway
manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
Open the patient’s airway using a head-tilt chin-lift manoeuvre\:
1. Place one hand on the patient’s forehead and the other under the chin.
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a
remove it.
Jaw thrust
If the patient is suspected to have su
than a head-tilt chin-lift manoeuvre\:
1. Identify the angle of the mandible.
2. With your index and other
lift the mandible.
3. Using your thumbs, slightly open the mouth by downward displacement of the chin.
Oropharyngeal airway (Guedel)
Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction
with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.
An oropharyngeal airway is a curved plastic tube with a
relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may
induce gagging and aspiration.
To insert an oropharyngeal airway\:
1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is
present, attempt removal using suction.
2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which
point you should rotate it 180°
. The reason for inserting the airway upside down initially is to reduce the risk of pushing the
tongue backwards and worsening airway obstruction.
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3. Advance the airway until it lies within the pharynx.
4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for
signs of breathing.
Nasopharyngeal airway (NPA)
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a
tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients
who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the
NPA.
To insert a nasopharyngeal airway\:
1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through
the
2. Lubricate the NPA.
3. Insert the airway bevel-end
4. If any obstruction is encountered, remove the tube and try the left nostril.
Other interventions
our anaphylaxis guide.
If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate\:
A normal respiratory rate is between 12-20 breaths per minute.
Tachypnoea in the context of AF may indicate pulmonary oedema secondary to heart failure or primary pulmonary
pathology which is driving AF with RVR (e.g. pulmonary embolism, pneumonia).
Review the patient’s oxygen saturation (SpO )\:
2
A normal SpO 2
range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk
of CO retention.
2
Hypoxaemia may be present in the context of heart failure secondary to AF with RVR.
Inspection
Observe the patient for evidence of pain, distress or anxiety.
Auscultation
Auscultate the lungs\:
Bibasal coarse crackles may suggest pulmonary oedema secondary to heart failure.
A focal region of coarse crackles may indicate an underlying infection which may be the trigger for AF with RVR.
Investigations and procedures
Arterial blood gas
Take an ABG if indicated (e.g. low SpO ) to quantify the degree of hypoxia and assess for metabolic abnormalities.
2
Chest X-ray
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A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for
evidence of AF triggers (e.g. pneumonia, pulmonary oedema). A chest X-ray should not delay the emergency management of
atrial
See our CXR interpretation guide for more details.
Sputum culture
Ask the nursing sta
productive cough.
This information can be useful later to understand the causative organism and its antibiotic sensitivities.
Interventions
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment if oxygen saturations are below the normal
range (\<94%). This typically involves the use of a non-rebreathe mask with an oxygen
and a history of CO 2
retention you should switch to a venturi mask as soon as possible and titrate oxygen appropriately.
If the patient is conscious, sit them upright as this can also help with oxygenation.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Circulation
Clinical assessment
Pulse
Assess the patient's pulse rate\:
Patients with AF with RVR will be tachycardic.
Blood pressure
Assess the patient's blood pressure\:
Most patients with AF will be haemodynamically stable, however, a minority may become haemodynamically unstable.
Haemodynamic instability is typically associated with prolonged periods of tachycardia (e.g. >150 bpm).
If a patient develops haemodynamic instability in the context of AF, urgent senior input should be sought as DC
cardioversion may be required to prevent cardiac arrest.
Capillary re
Capillary re
Fluid status assessment
Assess the patient's
Fluid status assessment involves\:
Inspecting the oral mucosa for hydration
Capillary re
Assessment of jugular venous pressure (JVP)
Review of the patient's
Hypovolaemia is a known trigger for AF and should be treated appropriately.
Apex beat
Locate and palpate the apex beat\:
The apex beat is typically located in the 5th intercostal space in the midclavicular line.
A displaced apex beat may indicate underlying ventricular hypertrophy.
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Investigations and procedures
Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
Blood tests
Collect blood tests after cannulating the patient including\:
FBC\: to rule out anaemia and to look for a raised white cell count which may suggest underlying infection.
U&Es\: to assess renal function and rule out electrolyte disturbances.
CRP\: to screen for evidence of in
Troponin\: if considering acute myocardial infarction or rate-related ischaemia.
Coagulation studies\: to assess for coagulopathy or assess the patient's current level of anticoagulation (e.g. INR).
Thyroid function tests\: to rule out hyperthyroidism which is a known trigger for AF.
ECG
An ECG should be performed to con
ECG
Irregularly irregular rhythm
Absence of P waves
See our ECG interpretation guide to learn more.
Interventions
Cardioversion
atrial
Emergency electrical cardioversion is required in people with life-threatening haemodynamic instability caused by new-onset
Consider either pharmacological (e.g.
and resources in people with new‑onset atrial
In people with atrial
long‑term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of
3 weeks. During this period o
Treating precipitating factors
AF is commonly triggered by other factors (see PIRATES above) and de
triggers to be addressed (e.g.
Rate control
In people with atrial ‑threatening haemodynamic instability, o
control if the onset of the arrhythmia is less than 48 hours, and start rate control if it is more than 48 hours or is uncertain.
Rate control is commonly required in the management of AF with rapid ventricular response. In the acute context, beta-
blockers (e.g. metoprolol) 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 individual patient characteristics (e.g. pre-existing cardiovascular disease, ejection
fraction). Generally, cardiac output is su
one drug may be required. If heart rate cannot be controlled to less than 110 bpm in the acute setting patients may require
admission under a medical team for further rate-controlling therapies.
Rhythm control
Rhythm control therapy is indicated to improve symptoms in patients who remain symptomatic on adequate rate control
therapy, it has not however been shown to improve long-term outcomes.
Rhythm control may be o‑threatening haemodynamic
instability.
Anticoagulation
Patients with AF are at increased risk of stroke from atrial emboli. Long-term oral anticoagulation with a suitable agent (e.g.
direct-acting oral anticoagulant or warfarin) signi
calculated using the CHA2DS2-VASc and ORBIT scoring tools respectively. In the acute setting, anticoagulation may be initially
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established using heparin.
Fluid resuscitation
Hypovolaemic patients require
Administer a 500ml bolus of Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
Administer 250ml boluses in patients at increased risk of
After each
Repeat administration of
reassessing the patient each time.
Seek senior input if the patient has a negative response (e.g. increased chest crackles) or if the patient isn’t responding
adequately to repeated boluses (i.e. persistent hypotension).
See our for more details on resuscitation
Diuretics
Consider administration of intravenous furosemide to treat pulmonary oedema\:
Furosemide will increase the patient's urine output and help to shift
As mentioned previously, if the patient is hypotensive then diuretics can precipitate hypovolaemic shock, therefore critical
care input should be sought to decide on the most appropriate management strategy.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Disability
Clinical assessment
Consciousness
stroke.
In the context of atrial
Assess the patient's level of consciousness using the AVPU scale\:
Alert\: the patient is fully alert, although not necessarily orientated.
Verbal\: the patient makes some kind of response when you talk to them (e.g. words, grunt).
Pain\: the patient responds to a painful stimulus (e.g. supraorbital pressure).
Unresponsive\: the patient does not show evidence of any eye, voice or motor responses to pain.
If a more detailed assessment of the patient's level of consciousness is required, use the Glasgow Coma Scale (GCS).
Pupils
Assess the patient's pupils\:
Inspect the size and symmetry of the patient's pupils
Assess direct and consensual pupillary responses
Drug chart review
Review the patient's drug chart for medications which may cause a reduced level of consciousness (e.g. opioids, sedatives,
anxiolytics, insulin, oral hypoglycaemic medications).
Investigations and procedures
Blood glucose and ketones
Measure the patient's capillary blood glucose level to screen for causes of a reduced level of consciousness (e.g.
hypoglycaemia or hyperglycaemia).
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
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The normal reference range for fasting plasma glucose is 4.0 - 5.8 mmol/l.
Hypoglycaemia is de≤4.0
mmol/L should be treated if the patient is symptomatic.
See our blood glucose measurement guide for more details.
Imaging
Request a CT head if intracranial pathology is suspected after discussion with a senior.
See our guide on interpreting a CT head for more details.
Interventions
Maintain the airway
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants
urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient's airway as
explained in the airway section of this guide.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Exposure
It may be necessary to expose the patient during your assessment\: remember to prioritise patient dignity and conservation of
body heat.
Clinical assessment
Inspection
Inspect for evidence of peripheral oedema (e.g. heart failure) or swollen painful calves (e.g. deep vein thrombosis).
Temperature
Measure the patient’s temperature\:
If fever is present, make sure to consider co-existing infection.
Interventions
Antibiotics
If an infection is suspected (e.g. consolidation on chest X-ray and fever) administer antibiotics as per local guidelines.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Re-assess ABCDE
Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the
e
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Support
You should have another member of the clinical team aiding you in your ABCDE assessment, such as a nurse, who can perform
observations, take samples to the lab and catheterise if appropriate.
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You may need further help or advice from a senior sta
about your patient.
Use an eSBARR handover to communicate the key information e
Next steps
Well done, you've now stabilised the patient and they're doing much better. There are just a few more things to do...
Take a history
Revisit history taking to explore relevant medical history. If the patient is confused you might be able to get a collateral history
from sta
See our history taking guides for more details.
Review
Review the patient's notes, charts and recent investigation results.
Review the patient's current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the
patient's response.
See our documentation guides for more details.
Discuss
Discuss the patient's current clinical condition with a senior clinician using an SBARR style handover.
Questions which may need to be considered include\:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist?
Should any changes be made to the current management of their underlying condition(s)?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.
References
1. ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal.
Published in 2016.
2. NICE guidelines. Atrial LINK].
Source\: geekymedics.com
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