Outline your approach to the management of rapid atrial fibrillation in the critically ill patient.
Management of atrial fibrillation requires consideration of urgency of treatment, reversal of potentially reversible causes, rate control, rhythm control and risks of thromboembolism. In the acute setting either rate control or reversion to sinus rhythm may provide haemodynamic benefits. Reversion to sinus rhythm is reasonable if atrial thrombi not expected (AF or more than 48 hrs duration or unknown duration). The use of trans-oesophageal echocardiography in excluding atrial thrombi is still uncertain (as not all thrombi identified). If reversion would add risks of thromboembolism then rate control and anticoagulation is preferred. In the presence of haemodynamic instability synchronised cardioversion (before or after administration of drugs/electrolytes) should be considered. If reversion is desired, correction of electrolytes (K and Mg) and specific drugs may be successful (eg. one of amiodarone [especially if impaired LV function], flecainide, procainamide, ibutilide or propafenone). If rate control only is desired then calcium channel blockers, beta-blockers or digoxin can be considered. Many critically ill patients are resistant to rate control with digoxin. Beta- blockers, calcium channel blockers and digoxin can be harmful if the rapid AF is due to Wolff-Parkinson-White syndrome.
Specific reversible causes may include drugs (eg. beta-agonists), mechanical stimuli (eg. guidewire, or catheters) and systemic disorders (eg. thyrotoxicosis, sepsis). Published guidelines (ILCOR, AHA) are available.
The question calls for a systematic approach.
Such an approach can be reviewed in the ILCOR guidelines, from which the local ARC guidelines are derived.
A fresh recently published article presents a lovely table of causes of AF in the ICU (Table 1) as well as a lucid and detailed discussion of the therapeutic options. My answer was largely modelled on these suggestions.
Hemodynamically stable patient:
Hemodynamically compromised patient
Investigation of causes, reversal of reversible factors, and preventative strategies
Morrison, Laurie J., et al. "Part 8: advanced life support 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations." Circulation 122.16 suppl 2 (2010): S345-S421.
Arrigo, Mattia, Dominique Bettex, and Alain Rudiger. "Management of Atrial Fibrillation in Critically Ill Patients." Critical Care Research and Practice 2014 (2014).