Atrial fibrillation with RVR: use POCUS to assess volume; then sinus vs. SVT: use of Lewis leads

An elderly man with a history of diabetes and HTN presented with lethargy and weakness, decreased urine output, and hypotension. There was no history of any GI bleeding or other hemorrhage. There was no fever. He had no CP or SOB, and it was unknown if there was a previous history of atrial fib. He was on atenolol, but it was not known if this was simply for hypertension, or for atrial fib.He was not anti coagulated.Blood pressures ranged from 83/45 to 125/83, lower than usual. HR ranged from 110 to 145.He had an ECG recorded upon arrival:There is atrial fibrillation with a rapid ventricular response (rate of approximately 120). There are aberrantly conducted beats (Ashmann ' s phenomenon), which are easily confused with runs of VT.There is ST depression in V2-V6 that is clearly ischemic.The ischemia on the ECG could be of several possible etiologies: 1) New atrial fib with RVR causing demand ischemia (but the rate is not terribly fast).2) Old atrial fib with poor rate control causing demand ischemia.3) ACS with possible additional ischemia from atrial fib with RVR4) Hemorrhage/dehydration/sepsis/etc., with new or old atrial fib, resulting in reflexive tachycardia and demand ischemia.To find the answer, it is wise to assess volume status, which can be done with ultrasound:A bedside ultrasound was done from the subcostal view, concentrating on the IVC. If this is due to etiologies 1-3, one would expect a full IVC. If etiology 4, the...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs