Acute Respiratory Distress and Pulmonary Edema

A 60-something called 911 for respiratory distress of acute onset. Medics found him hypoxic with wet sounding lungs. He was put on CPAP with improvement. BP was 250/140 by manual measurement.He was brought to the ED. There was vomitus in his CPAP mask, and he began vomiting again.He was intubated before he could even be placed on a cardiac monitor.A bedside echo was performed.There is an irregularly irregular rhythm with rapid response.The myocardium is very thick (concentric ventricular hypertrophy)There is very little ventricular filling, and thus very little cardiac output.There is good LV functionThere were many B lines and a very filled inferior vena cava.Obviously, even without an ECG or monitor, this is atrial fibrillation with rapid ventricular response.What do we do?1. Immediately cardiovert? This will restore the important atrial contribution to ventricular filling, and we can see that ventricular filling is a big issue. This will only work reliably inparoxysmal atrial fib. Chronic atrial fib is unlikely to convert. Furthermore, if it is chronic, then there is a stroke risk.2. Slow the rate with an AV nodal blocker? Diltiazem? Esmolol?  This will not restore the atrial contribution, but will slow the ventricular rate and allow for more filling.3. Give diuretics?This will worsen ventricular filling.Figuring out whether this is chronic or paroxysmal is important.The big question is: What initiated the critica...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs