The most common cardiac arrhythmia, atrial fibrillation, occurs when the normal electrical impulses that are generated by the SA node are overwhelmed by disorganized electrical impulses in the atria.
These disorganized impulses cause the muscles of the upper chambers of the heart to quiver (fibrillate) and this leads to the conduction of irregular impulses to the ventricles.
For ACLS, atrial fibrillation becomes a problem when the fibrillation produces a rapid heart rate which reduces cardiac output and causes symptoms or an unstable condition.
When atrial fibrillation occurs with a (RVR) rapid ventricular rate (rate > 100 beats/min), this is called a tachyarrhythmia. This tachyarrhythmia may or may not produce symptoms. Significant symptoms that occur are due to a reduction in cardiac output.
The following is a list of the most common symptoms.
- palpitations or chest discomfort
- shortness of air and possibly respiratory distress
- hypotension, light-headedness and possibly loss of consciousness
- peripheral edema, jugular vein distention, and possibly pulmonary edema
For the purpose of ACLS, it is important to be able to recognize atrial fibrillation when the patient is symptomatic. On an ECG monitor, there are two major characteristics that will help you identify atrial fibrillation.
- No p-waves before the QRS on the ECG. This is because there are no coordinated atrial contractions.
- The heart rate will be irregular. Irregular impulses that the ventricles are receiving cause the irregular heart rate.
When the heart rate is extremely rapid, it may be difficult to determine if the rate is irregular, and the absence of p-waves will be the best indicator of atrial fibrillation.
ACLS Treatments:
For the purposes of ACLS atrial fibrillation is treated when the arrhythmia/tachyarrhythmia produces hemodynamic instability and serious signs and symptoms.
For the patient with unstable tachycardia due to a tachyarrhythmia, immediate cardioversion is recommended. Drugs are not used to manage unstable tachycardia. The appropriate voltage for cardioverting unstable atrial fibrillation is 120-200 J.
Cardioversion of stable atrial fibrillation should be performed with caution if the arrhythmia is more than 48 hours old and no anticoagulant therapy has been initiated due to the risk of emboli that can cause MI and stroke.
Below is a short video which will help you quickly identify atrial fibrillation on a monitor.
Please allow several seconds for the video to load. (5.11 mb)
Click for next Rhythm Review: Other Tachycardias
Top Questions Asked On This Page
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Q: To treat a patient with rapid atrial fibrillation (HR >180bpm), can calcium channel blockers be given to help control the rate?
A: Yes, in some cases, calcium channel blockers are a good choice to help control atrial fibrillation with a rapid ventricular rate.
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Q: What are atrial fibrillation and atrial flutter considered in terms of narrow or wide QRS complexes?
A: Unless there is an underlying block the QRS complex will typically be normal/narrow. There is the possibility of occasional wide QRS complexes due to abnormal ventricular depolarization via an accessory pathway.
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Q: What does the DC before the word cardioversion stand for?
A: DC cardioversion simply means direct current cardioversion.
Desiree Archer says
Have been randomly looking at sites in preparation for ACLS test. I must say this website is EXCELLENT!!! I am a visual learner so the combination learning exceeds my expectation. Thank you Jeff.
Regards
Desiree A.
Arlene says
I had a patient who came into the Ed with heart palpitations and slight left upper arm ache and stiffness, HR 218, EKG diagnosed AFIB with RVR but the ventricular rate was quite regular, is this possible? There were some obvious P waves in some of the complexes, could it be SVT
Jeff with admin. says
With a rate that rapid, it may be impossible to distinguise an irregular rate. I’m not sure how you could even see any p waves with a rate that fast. You would need to slow the heart rate down to see the underlying pattern. A rate that fast should be treated because symptoms will soon arise. The patient should have been administered a medication like a cardizem to slow the rate. If the rate could not be reduced, cardioversion would be indicated.
Slowing the rate down would allow you to see if you were truly dealing with SVT or atrial fibrillation.
Kind regards,
Jeff
Jahan says
I am a newbie and still to take an ACLS course. These tools made me easier to understand the different tracings compared to just merely reading a context. Thank you for this brilliant video clips.
Christina1 says
Jeff,
This is the most valuable learning tool I have ever utilized on-line. Thank you so much for all the great megacode scenarios and rhythm strips. Taking my certification test today, and feeling much more prepared then when I began this process!
Sincerely,
Christina
Jeff with admin. says
Thank you for the feedback. I’m so glad that the site has was helpful for you. Kind regards, Jeff
gamboam says
Hi Jeff,
Great website.
What are atrial fibrillation and atrial flutter considered in terms of narrow or wide QRS complexes? What would you give them if STABLE? Thanks.
Jeff with admin. says
Unless there is an underlying block the QRS complex will typically be normal/narrow. There is the possibality of occasional wide QRS complexes due to abnormal ventricular depolarization via an accessory pathway.
Kind regards,
Jeff
m_harder55 says
Hi Jeff,
I have a question, to treat a patient with a rapid atrial fibrillation (HR >180bpm), can calcium channel blockers be given to help control the rate? Thanks ?
Jeff with admin. says
Yes, in some cases, calcium channel blockers are a good choice to help control atrial fibrillation with a rapid ventricular rate.
Kind regards,
Jeff
m_harder55 says
Thanks Jeff ?
Holly says
How is the atrial rate of 300-600bpm counted if there are no P Waves?
Jeff with admin. says
You cannot count the atrial rate when a patient has atrial fibrillation because the atrial impulses produce a quivering of the heart rather than a full impulse which creates a p-wave. Regarding atrial rates that are very rapid, You may be referring to atrial flutter. With atrial flutter, the flutter waves between the QRS complexes can be very rapid and these can counted as a separate atrial rate to determine the rate at which the atria is firing compared to the ventricles.
Ron MD says
pt 70 yrs old with AF on two occasions lasting up to three hours with HR of 130-150 (linqes monitor)-spontaneous converts to sinus rhythm each time. On Xerolto with cad score of >2 on Beta blocker. Patient travel to remote areas. The Afib causes anxiet but nothing else. At what point is intervention needed and with what if he is traveling remotely. For how long (hours, days, weeks) is it safe for AFib with RVR.
Jeff with admin. says
The patient should probably have a continuous halter monitor study to ensure that there is not any prolonged atrial fibrillation occurring. The concern with prolonged atrial fibrillation is the potential for a blood clot develop in the heart because of the atrial fibrillation. The patient may also benefit from a cardiac workup to ensure that there are not any other cardiac issues.
Kind regards,
Jeff
Maureen Cutright says
I read through the guidelines, but treatment recommendation seem more vague than other guidelines. How would you treat a 63 year old patient with new onset A. fib who has a history of NSTEMI involving the LAD and OM1 in 2014, T2DM, HTN, CAD, and Stage III NYHA chronic heart failure. The A. fib seems to have caused her HF to decompensate. Her BP is 128/76 and her ventricular rate is 137. Also she has LVH. Elevated BUN and SCr of 1.3 and normal electrolytes. Would you use electrical cardioversion, amiodarone or dofetilide? Someone who works in ER said that clinically a physician would not consider performing electrical cardioversion unless their ventricular rate was at or above 160 and had hypotension.
Jeff with admin. says
Your above scenario would be treated using the ACLS algorithm for stable tachycardia. Atrial fibrillation with a rapid ventricular rate would be treated with medications like calcium channel blockers, but considering the comorbidities of the patient in your scenario, you would probably just go straight to an expert consultation with a cardiologist prior to any treatment.
Kind regards,
Jeff
mahesh kumar says
atrial fibrillation patient aged 65 developed edema in legs. treated with furosemide for 4 weeks. but the symptoms still there. no shortness of breath,fatigue, no chest pain
why this happen what is further teatment
mahesh
Jeff with admin. says
There could be a number of causes. Probably the most common would be congestive heart failure. Sometimes when the heart is not working as well, this fatigue and shortness of breath can continue even after the use of a diuretic. In a situation like this, the patient should have some cardiology testing. Without knowing the cause, it would be hard to say what the further treatment would be. Kind regards, Jeff
bhersheyfell says
What causes jugular vein distention?
Jeff with admin. says
Jugular vein distention is caused by increased blood volume, which can occur with heart failure, or anything that interferes with filling of the right atrium or movement of the blood into the right ventricle, can increase the central venous pressure and the amount of jugular vein distention.
Kind regards,
Jeff
James says
Very helpful ! Ty
Cmulvany says
It’s probably obvious to most, but what does the DC before the word cardioversion stand for?
Jeff with admin. says
DC cardioversion simply means direct current cardioversion.
Kind regards,
Jeff
NCnurseAW says
What is the best way to distinguish between a P waves and a T wave on the rhythm strip?
( For instance, the Afib with RVR video clip from 0:50 seconds – 1:11 appears to have P waves, however, I am assuming that they are T waves.) How can I best tell the difference?
Thanks!
Jeff with admin. says
The first thing you need to ask is “is the rhythm irregular?” If the rhythm is irregular then you are most likely dealing with atrial fibrillation. The second thing is “is there a P-wave before every QRS complex?”
If you do not see a p-wave before every QRS complex and the rhythm is irregular then you are almost guaranteed that the patient is in atrial fibrillation. Don’t worry about figuring out anything about the t-waves. Just ask yourself “is the rhythm irregular” and “is there a p-wave preceding every QRS complex.
If the rate is too rapid to assess p-waves but the rhythm irregular, then you can assume that the patient is in atrial fibrillation.
I hope that makes sense. Please let me know if you have any other questions.
Kind regards,
Jeff
Chris says
I think this is the best website/ books on ACLS until proven wrong. Indeed, it is truly made simple!
Jeff with admin. says
Thanks for the encouraging words. Making mastery of ACLS simple is my main hope for those who use the site. Kind regards,
Jeff