Cardioversion tomorrow

Re: Cardioversion tomorrow

susan.d — Wed, 22 Jan 2020 17:10:36 +0000

Kate- this ER is divided into two tiers- one is cuts and such, the other is cardiac and more serious. I speculate they classify AF the higher tier than a broken bone or stitches or getting your eye exam. This higher tier has vacant beds and is less crowded with two doctors, sometimes one. I once got something in my eye and was put with the general tier. Same with multiple times in the past when I fainted and cut my scalp and needed stitches. The general tier, being crowded, takes longer to get a bed and it’s hours and hours from start to finish - middle of night though it maybe less time in and out.

The two tiers are basically a triage classification in its own.

Re: Cardioversion tomorrow

katesshadow — Wed, 22 Jan 2020 15:21:16 +0000

Quote
susan.d
Liz, ER’s cardio converts all the time. I trust them. The only time my cardiovert wasn’t in the ER was during my ablation under the gifted hands of the master Natale.
Regarding routine description: Maybe because they know me at the ER by sight or it’s in their computer details, I am greeted by security and I pass through an TSA type X-ray arch and my purse is checked, I’m asked why I am there and I say AF and they get a wheelchair which is stacked in a corner and wheel me to one part of the ER (the other side is non urgent cuts, broken bones etc). Once I enter the higher tier ER I am greeted by passing staff or doctors on the way to triage asking me if it’s AF again before I reach triage where my name is entered, computer screen up and vitals and ekg is given. Then I am wheeled to a room and greeted by my assigned nurse who recognizes me and I ask who is on duty that night (it’s always in the night) and that I have AF and request a cardiovert. I then ask which nurses are on duty because some are vein whisperers and can insert an IV without popping my veins. This may be my only ER concern due to chemo destroyed/burned most of my good veins. I pick a good vein and get jabbed. I am asked if I am still on Eliquis and if I have returned abroad the past 10 days? Only once it was less than 10 days from flying and for precaution because of my history of DVT, I was required to get a TEE. That was the only time I wasn’t in and out.

I just flew home Saturday night and stopped Multaq so the next week window I hope I am AF free because it took 5 hours to get a TEE and be converted that one time after flying. The other times the assigned doctor arrives and I request a cardiovert with "a push of 50 of propofol and 50 joules” because that dose works for me. While they setup, admission arrives for a signature (my insurance is on file), and an X-ray is taken, I get converted and a RN sits with me for an hour and I go home.

I am fortunate to had found this particular hospital. It’s not the closest to my home, there are many closer but with the others I would get the negative dragged out experience Carey commented he described. I take a Lyft to a further ER that is cardiovert friendly. Because it’s not the closest, I once naturally converted once in the car and the driver turned around.

Susan, why are you taken to the "higher tier" ER? It's great that you are given such quick attention since from what I understand, Afib is not usually considered urgent.

Re: Cardioversion tomorrow

susan.d — Wed, 22 Jan 2020 04:06:22 +0000

Liz, ER’s cardio converts all the time. I trust them. The only time my cardiovert wasn’t in the ER was during my ablation under the gifted hands of the master Natale.
Regarding routine description: Maybe because they know me at the ER by sight or it’s in their computer details, I am greeted by security and I pass through an TSA type X-ray arch and my purse is checked, I’m asked why I am there and I say AF and they get a wheelchair which is stacked in a corner and wheel me to one part of the ER (the other side is non urgent cuts, broken bones etc). Once I enter the higher tier ER I am greeted by passing staff or doctors on the way to triage asking me if it’s AF again before I reach triage where my name is entered, computer screen up and vitals and ekg is given. Then I am wheeled to a room and greeted by my assigned nurse who recognizes me and I ask who is on duty that night (it’s always in the night) and that I have AF and request a cardiovert. I then ask which nurses are on duty because some are vein whisperers and can insert an IV without popping my veins. This may be my only ER concern due to chemo destroyed/burned most of my good veins. I pick a good vein and get jabbed. I am asked if I am still on Eliquis and if I have returned abroad the past 10 days? Only once it was less than 10 days from flying and for precaution because of my history of DVT, I was required to get a TEE. That was the only time I wasn’t in and out.

I just flew home Saturday night and stopped Multaq so the next week window I hope I am AF free because it took 5 hours to get a TEE and be converted that one time after flying. The other times the assigned doctor arrives and I request a cardiovert with "a push of 50 of propofol and 50 joules” because that dose works for me. While they setup, admission arrives for a signature (my insurance is on file), and an X-ray is taken, I get converted and a RN sits with me for an hour and I go home.

I am fortunate to had found this particular hospital. It’s not the closest to my home, there are many closer but with the others I would get the negative dragged out experience Carey commented he described. I take a Lyft to a further ER that is cardiovert friendly. Because it’s not the closest, I once naturally converted once in the car and the driver turned around.

Re: Cardioversion tomorrow

Elizabeth — Tue, 21 Jan 2020 21:26:32 +0000

Carey;

Thanks Carey, I didn't know that the ER would do that, my heart rate has never gone over 100 so I guess I would have to sit there a long time.
They were very through at U of M but perhaps it was overkill. I wouldn't do that again, too far and a long day and I am not sure I am in NSR, my heart beat feels normal when sitting and relaxing but moving around, going up and down the stairs etc., heartbeat seems overly fast. I have my pacer and will send a reading in probably tomorrow. My monitor doesn't show that I am in AF, it always did before, and I could always tell if I was in AF, but after going into AF permanently it changed I don't feel my heart jumping around like it used to do.

Liz

Re: Cardioversion tomorrow

Carey — Tue, 21 Jan 2020 20:51:04 +0000

Yes, you have to have been on an anticoagulant for at least 3 weeks. Less than that and a TEE will be required first. You also need to have not had anything to eat for 5 hours. All they can do is take your word for it.

You don't make arrangements in advance. It's an ER, after all, so you just walk in. Now, if you walk into the average big city ER with afib, stable vitals, and a heart rate that's not super fast, odds are you're going to be in the waiting room a long time. And unless you find a cardioversion-friendly ER like Susan did, they may not do one at all since it's not an emergency. But I used to walk in with a heart rate of 250, so that got me immediate attention and a cardioversion without question.

As for how many joules, it's doctor's choice. It will usually be either 100 or 200 joules. Doesn't depend on size or sex. I've even had ER doctors ask me what to use since I'd been there so often. I got in the habit of telling them right off that all I needed was "100 of propofol and 100 joules." They always did just as I asked.

They'll also insist that someone else drive you home, but I would just lie and tell them I was calling a cab. I'd pretend to make a phone call then go stand by the doors like I was waiting for my cab. As soon as they quit paying attention to me, I'd just walk out and get in my car and drive home. That's what I love so much about propofol. Twenty minutes later I'm 100% clear headed and perfectly capable of driving.

Not sure what other things you asked about, but in general an ER can do a cardioversion just as competently as any EP.

Re: Cardioversion tomorrow

Elizabeth — Tue, 21 Jan 2020 20:31:38 +0000

Carey:

Do you have to be on a anti-coagulant, and how do they know if you really are, do they use a Tee first?

Well that is good to know, I had to drive to Ann Arbor which is about an hours drive from my house, also, I had to get someone to come with me as they did not want me to drive back. How about eating/drinking water, do you have to stop all for a time? Do you make arrangements in advance and does a doctor have to do that? How many joules do they use, does it depend on your size and sex?

The skill can be there but what about all the other things I asked about?

Liz

Re: Cardioversion tomorrow

Carey — Tue, 21 Jan 2020 20:08:35 +0000

I've been cardioverted in an ER over a dozen times and wouldn't hesitate to do so again if needed. It takes about an hour, and almost all of that is spent just lying there bored waiting for the drugs to wear off.

It really is a trivially simple procedure that doesn't even begin to require the skills of an EP. Literally all it requires is knowing how to calculate a drug dosage, knowing where to place two pads, and knowing which two buttons to push. It's a skill paramedics can do in your living room or the back of a moving ambulance.

Re: Cardioversion tomorrow

Elizabeth — Tue, 21 Jan 2020 19:18:52 +0000

I was cardioverted last thrusday, I arrived at 9:30 AM., it took the team an hour and a half to prep me for my 11:00 A.M cardiovert. They ran a ECG and also an Echo, I was given a drug to put me out before they put in the tee and cardioverted me. When I woke up it was all over, I felt nothing. I left around 2:00, so I was there about 4 and a 1/2 hours.

When you go to the ER, I am sure they don't do all of the above, do they use a Tee or if someone says they were on a blood thinner how do they know that they really have been? I had gone to the ER about 3 weeks ago because Of blood in my stool, I was in AF also, they said nothing about my AF or that they could cardiovert me. I wouldn't want to be cardioverted by the ER anyway.

Liz

Re: Cardioversion tomorrow

susan.d — Tue, 21 Jan 2020 18:37:56 +0000

The NP was right. AF isn’t bad when compared to a heart attack, heart failure or other cardiac issues seen in the ER.
She should had explained AF to you to reduce your anxiety.

Re: Cardioversion tomorrow

katesshadow — Tue, 21 Jan 2020 15:57:46 +0000

Quote
susan.d

. My pet peeve is an ER doctor who would say there is nothing wrong with living in AF. Let him try out my AF and get back to me “how does he like it?”

I was diagnosed with Afib in Nov. 2018. I went to the ER after several hours of my heart racing, didn't realize it was out of rhythm (but knew I didn't feel right :).

The ER doc took one look at the ECG and said I was in Afib. Like in all ERs, several ppl came in and out, but no one explained Afib to me. I was scared to death. One NP, who was just getting info from me, said "if you have to have anything with your heart, it's Afib." Her was of saying "no big deal."

Re: Cardioversion tomorrow

susan.d — Tue, 21 Jan 2020 15:14:16 +0000

Quote
Carey

I'm all about minimizing time out of rhythm, but the ER trip is my last, not first resort.

Exactly. For most people the ER isn't where you want to be during an afib episode.

It's very unlikely they'll do anything useful for you and sure as heck unlikely they'll cardiovert you unless you have a super-high heart rate or are in distress.

I must have picked a cardiovert friendly ER because I walk in and they are willing to cardiovert me even if my HR is under 100 a few times. Bottom line, at the end of the day it’s my heart and I elect not to be in AF. My pet peeve is an ER doctor who would say there is nothing wrong with living in AF. Let him try out my AF and get back to me “how does he like it?”

I stopped Multaq 24 hours ago on the advise of Natale’s office. It’s been 4 months. I hope I don’t get AF and the ablation was a success and I hope never having to go to the ER. I don’t enjoy being zapped but I hate being in AF worst because I can’t walk around without being lightheaded and it’s not a quality of life I prefer.

“ For most people the ER isn't where you want to be during an afib episode.”
I prefer in fact being in AF at the ER with symptoms than alone at home being a fall risk and all.

Re: Cardioversion tomorrow

The Anti-Fib — Tue, 21 Jan 2020 10:08:38 +0000

Quote
Carey

I'm all about minimizing time out of rhythm, but the ER trip is my last, not first resort.

Exactly. For most people the ER isn't where you want to be during an afib episode.

It's very unlikely they'll do anything useful for you and sure as heck unlikely they'll cardiovert you unless you have a super-high heart rate or are in distress.

If you want an ER ECV, and you are not very symptomatic, then the way to do it is to contact your Cardiologist/EP, and inform them you want to go to the ER and get Cardioverted. If they approve, or it is likely that they will approve with a call from an ER Doc, then proceed to the ER. Try to find an ER room that is not very busy. When you arrive at ER, tell them that you were sent there by Dr. "so and so" to get Cardioverted, and to call Dr' "so and so", if they want his advice/directive. In my experience this works almost every time, unless you a run into a very inexperienced ER Doc. The patient needs to be calmly firm and resolute that an EVC is the thing to do, and be prepared to argue or lobby your position.

Re: Cardioversion tomorrow

Carey — Tue, 21 Jan 2020 06:18:28 +0000

Quote
GeorgeN
I'm all about minimizing time out of rhythm, but the ER trip is my last, not first resort.

Exactly. For most people the ER isn't where you want to be during an afib episode.

It's very unlikely they'll do anything useful for you and sure as heck unlikely they'll cardiovert you unless you have a super-high heart rate or are in distress.

Re: Cardioversion tomorrow

susan.d — Tue, 21 Jan 2020 04:08:14 +0000

Carey,
1. I have great insurance. Free after my Medicare and PPO’s low out of pocket is reached.
2. I don’t waste 6+ hours in the ER, it’s more like 2 tops including the hour post c. Conversion.
3. Triage tells me to return upon onset of AF. I listen to their advise.
4. As I mentioned if I had controlled low hr I don’t rush to the ER. It’s the strong urge to faint. I was tested positive for the tilt table test. The cardiologist got my BP down to 44/24. Not a good feeling to be symptomatic. I have awoken in a puddle of blood more than once after fainting. I kind of slither and faint. Twice backwards. I started going quicker to the ER the last time I fainted backwards because my scalp got caught in the spikes of the window AC box and the spikes hooked into my scalp 4” and the tear broke the fall onto the concrete.

I agree if one isn’t as symptomatic or is not advised by the ER triage to immediately come in, I would wait and see. In March 2019 I was in a remote foreign village and I had to wait it out 22 hours until I self converted. I had no choice. I was in a basement apt with stairs to the parking lot where there is a mountain goat steep hill to a street. I didn’t have food or WiFi or cellular service to call anyone down in the bomb shelter basement rental. Thick concrete and steel walls. Not good. I was so faint’ish I couldn’t do the stone stairs to civilization . Everyone was away flying to the states for my mom’s funeral and I was left alone. After that experience I appreciated the ER more. I think if one is elderly, alone and symptomatic, they should seek medical care.

I think going to the ER is person to person decision based on symptoms. I envy you handling your hr. Not everyone can.

Re: Cardioversion tomorrow

GeorgeN — Tue, 21 Jan 2020 03:46:34 +0000

Quote
Carey
But just waiting it out at home was better than waiting it out in an ER at $3000 per visit.

From 1987 till I remarried in 2015, I had very high deductible individual health insurance. In 2004, the ER trip cost over $3000, and I converted on my own without meds (was my first ever afib episode) or electro cardioversion. I learned then that an ER visit wasn't for me for afib. I would go if I was out of rhythm long enough and felt I needed to be cardioverted, but I've been blessed that flec, exercise or exhaled breath holds have worked in relatively short order. I'm all about minimizing time out of rhythm, but the ER trip is my last, not first resort.

Re: Cardioversion tomorrow

Carey — Tue, 21 Jan 2020 02:30:28 +0000

Quote
susan.d
My question is why do you wait it out? You must not be symptomatic otherwise why wouldn’t you want to go to the ER for 2 g of magnesium and drugs to get rid of the AF if it works and if all else fails get cardio converted?

I don't know about Liz but I can answer this for me.

1) Because it's not an emergency.

2) Because I had better things to do with the next 8+ hours of my life than lying in an ER with a diltiazem drip that would slow my rate but do nothing otherwise. I could do the same thing by just relaxing at home. There are damn few ERs in the US that will do more for uncomplicated afib than a diltiazem drip and a bed in the corner where you're not much trouble to the staff. If you don't have serious symptoms such as fainting, dizziness, or a super high heart rate, going to an ER with afib is a complete waste of time and money for most people. And I assure you I was far from asymptomatic. My afib usually ran at rates upwards of 170 bpm and I felt every one of them. But just waiting it out at home was better than waiting it out in an ER at $3000 per visit.

Re: Cardioversion tomorrow

susan.d — Tue, 21 Jan 2020 01:45:32 +0000

Quote
Elizabeth
Susan:

You are only in AF for 1 hour when you go to ER? They don't cardiovert you after only 1 hr. in AF do they? Most of us wait our AF episodes out.

Sorry about your foot.

Liz

Yes in the past I would head to the ER upon AF when my HR was high. I was instructed by the ER to come once my AF begins...and the triage would remember me and make a comment to thank me for taking their advise. Then throughout the years I would be less symptomatic hr wise and I would try to convert myself by taking low sodium V8, a Valium (it lowered my hr), a beta blocker if the prior was far enough apart and a flecainide if the prior dose before was at least 8 hours (would then not take a flecainide during my evening dose) first instead of directly going to the ER after an hour. I would usually convert on my own. In March 2019 my mom died and I had a marathon of AF so once the AF would appear I would take a Lyft to the ER. The triage or even the ER doctor if he/she happened to be passing by would say “get the crash cart ready we are going to cardio convert”. I was in and out. Easy peasy. I know all the nurses and doctors. It got to the point of once a week visits to get cardio converted so I had an ablation done. The reason they were willing to cardio converted was because I had no ill effects/problems with being cardio converted and they respected my wishes of not remaining in AF for atrial remodeling.

You may think it’s overkill to rush to the ER but I didn’t like being in AF. Now I don’t like my constant PVCs but I live with them with high hr as long as I don’t feel like fainting. PVCs resembles the same sometimes as AF. I’m very symptomatic. I have a history of fainting and have a roadmap of head scars from being stitched up. Being on Eliquis I’m not taking any chances of falling and hitting my head AGAIN. 2 weeks after my ablation I was shopping at a vitamin sho and my hr was at least in the 180s and I was looking for a soft spot in case I fainted. I had high tachy. I asked the cashier to call 911 and an ambulance came by. They took me to the ER and kept for observation for a few hours. It happened again about a month ago (Carey said my ekg was PVCs with tachy) but I was so dizzy I thought I would faint but luckily it only lasted 5-7 minutes.

My question is why do you wait it out? You must not be symptomatic otherwise why wouldn’t you want to go to the ER for 2 g of magnesium and drugs to get rid of the AF if it works and if all else fails get cardio converted? I don’t know how often you get AF or how long is the duration, but aren’t you a tad concerned about atrial remodeling?

Re: Cardioversion tomorrow

Elizabeth — Mon, 20 Jan 2020 20:02:12 +0000

Susan:

You are only in AF for 1 hour when you go to ER? They don't cardiovert you after only 1 hr. in AF do they? Most of us wait our AF episodes out.

Sorry about your foot.

Liz

Re: Cardioversion tomorrow

susan.d — Mon, 20 Jan 2020 19:54:20 +0000

It seemed to be successful with 50. I never remained in AF longer than an hour (or less) before visiting the ER. Maybe it’s my body that 50 works. Maybe because I don’t wait to be cardio converted after a longer AF -“AF begets AF”. One ER dr insisted on 200 and I couldn’t reason with him, another compromised with 75. A dozen plus maybe with 50. My first cardio conversion they made me wait a day and had to shock me twice. I think 100 and 200. It was her third day as an attending so I contributed it to that and waiting. My ablation 4 times total at 200,200,200,300. I had blisters on my back pad area from that.

I was supposed to had stopped multaq Sunday but Saturday in the Middle East right before getting on the plane a heavy chair fell on my foot. It’s painful, swollen, so I just emailed natale office if I can remain on the multaq until I see the ortho guy tomorrow. Pain was an AF trigger for me and I don’t want to risk AF (however I have confidence he did a good job) nevertheless I rather not have another cardio conversion. My blood pressure is >160 from the pain. Before the ablation I would had gone into AF.

Re: Cardioversion tomorrow

Elizabeth — Mon, 20 Jan 2020 19:20:33 +0000

If 50 Joules doesn't convert you isn't that a waste of time.?

Also were you in AF or flutter, I read that lower doses of Joules are used to convert if you are in flutter.

Re: Cardioversion tomorrow

susan.d — Mon, 20 Jan 2020 18:29:24 +0000

I don’t do well with joules higher than 50. I get real weak and dizzy afterwards. My local EP told me before my ablation to always ask for 50. ER prefer 200 to start so they don’t have to cardio converted a second time. I was able to ask for 50 most of the time.

I actually asked dr natale during my three month post appointment why he cardio converted me four times-200,200,200,300? He didn’t recall doing it. I had the report. I don’t care about the burn (like a sunburn), I care about how it affects me afterwards but it’s worth not being in AF. If I had to speculate, I probably had close to 20 cardio conversions. It was no big deal as long as they did 50 joules.

Re: Cardioversion tomorrow

katesshadow — Mon, 20 Jan 2020 15:08:51 +0000

Quote
Carey
There are several videos of cardioversions on youtube if you want to know how it really looks.

This one is my favorite. It's amusing and it demonstrates why you should never allow yourself to be talked into a cardioversion under conscious sedation. Demand full sedation.

I watched the one after that (automatically went to it). It was an ER doctor in his 70s. He has had Afib since his late 30s. He worked that day (while in Afib) and stopped by on his way out to be cardioverted.

I wish I could be so calm. Some of you just seem to take it in stride. I had my first (and only documented) episode in Nov. 2018. Since then, no episodes (thanks to the meds I guess), but if I have a skipped beat/weird feeling, I instantly start to panic. HATE that feeling.

Re: Cardioversion tomorrow

GeorgeN — Sat, 18 Jan 2020 12:05:12 +0000

Quote
Daisy
I wonder if they could convert an Afib patient (who also had an implanted defibrillator) by activating it
.

Not all ICDs have atrial leads.

In this study of using ICDs to convert afib, conversion rates were low - like 27%. < [www.ncbi.nlm.nih.gov]

Re: Cardioversion tomorrow

Elizabeth — Sat, 18 Jan 2020 05:14:13 +0000

Daisy:

Sometimes when a person is cardioverted they can have a burn on their chest but you wouldn't want it directly on your heart.

Re: Cardioversion tomorrow

Daisy — Sat, 18 Jan 2020 05:01:24 +0000

Quote
Carey

I wonder if they could convert an Afib patient (who also had an implanted defibrillator) by activating it?

If it were programmed to do so I don't see why not, but they'd have to be super-careful with the programming. For example, an ICD shock is a decidedly unpleasant event, so they'd have to set a limit on how many shocks it would deliver. It's one thing to try endlessly to terminate a lethal rhythm because the alternative is death, but it's quite another to keep shocking someone who's gone into persistent afib. And what about shocking someone while they're driving down the interstate, climbing a ladder, or doing eye surgery? I think it would need to include a warning a shock was coming and offer a way to cancel it.

Interesting idea but I've got a feeling we won't be seeing ICDs for afib anytime soon because the view would be it's a very expensive band-aid with significant complications for a non-lethal disease and significant risks for the manufacturers. I can hear Mandrola howling about it now. ;-)

And that is an even more interesting idea. I was actually just wondering what if an Afib patient had an ICD for the usual reasons and they went into a few days of Afib, that maybe their EP/Cardiolgist could convert them by activating their ICD in their office. There must be a way to do it by getting into the settings—and though it wouldn’t be pleasant it would be better than persistent Afib.

Re: Cardioversion tomorrow

Carey — Sat, 18 Jan 2020 02:13:40 +0000

Quote
Daisy
I wonder if they could convert an Afib patient (who also had an implanted defibrillator) by activating it?

If it were programmed to do so I don't see why not, but they'd have to be super-careful with the programming. For example, an ICD shock is a decidedly unpleasant event, so they'd have to set a limit on how many shocks it would deliver. It's one thing to try endlessly to terminate a lethal rhythm because the alternative is death, but it's quite another to keep shocking someone who's gone into persistent afib. And what about shocking someone while they're driving down the interstate, climbing a ladder, or doing eye surgery? I think it would need to include a warning a shock was coming and offer a way to cancel it.

Interesting idea but I've got a feeling we won't be seeing ICDs for afib anytime soon because the view would be it's a very expensive band-aid with significant complications for a non-lethal disease and significant risks for the manufacturers. I can hear Mandrola howling about it now. ;-)

Re: Cardioversion tomorrow

Daisy — Sat, 18 Jan 2020 00:14:27 +0000

Quote
Carey

How many joules does an implanted defibrillator deliver?

Much lower, down in the 10-40J range. Since it's attached directly to the heart you don't need a bunch of energy to get through the impedance of the skin, chest wall, etc.

I wonder if they could convert an Afib patient (who also had an implanted defibrillator) by activating it?

Re: Cardioversion tomorrow

Carey — Fri, 17 Jan 2020 22:45:55 +0000

Quote
Daisy
How many joules does an implanted defibrillator deliver?

Much lower, down in the 10-40J range. Since it's attached directly to the heart you don't need a bunch of energy to get through the impedance of the skin, chest wall, etc.

Re: Cardioversion tomorrow

Daisy — Fri, 17 Jan 2020 21:43:16 +0000

How many joules does an implanted defibrillator deliver?

Re: Cardioversion tomorrow

Carey — Fri, 17 Jan 2020 21:27:34 +0000

There are several videos of cardioversions on youtube if you want to know how it really looks.

This one is my favorite. It's amusing and it demonstrates why you should never allow yourself to be talked into a cardioversion under conscious sedation. Demand full sedation.