The correct answer is A. This patient has acute atrial fibrillation (AF) with rapid ventricular response (RVR) and is consequently hypotensive. This is a medical emergency. Even the health care provider caring for this patient is ill equipped to deal with a potentially life-threatening episode of AF with RVR. Activating the emergency medical response system is always appropriate and ensures that trained persons who have additional equipment and medications appropriate to an emergency situation will be on hand as soon as possible. The patient will need to have IV access, intravenous fluid support, and medication or cardioversion as part of the treatment regimen. According to the Advanced Cardiac Life Support protocol, a patient who has atrial fibrillation with a rapid ventricular response who is hypotensive should be cardioverted, something that emergency medical personnel will have available to them.
Giving the patient an oral dose of a beta-blocker (choice B) , digoxin (choice C) , or a calcium-channel blocker (choice D) is not appropriate for an emergent setting. These medications will take too long to be effective. These agents are not typically used to cardiovert patients who are in acute atrial fibrillation. Beta-blockers and calcium-channel blockers should not be given to patients who are already hypotensive, because this will further lower blood pressure and make the patient worse. Digoxin may be used in rate control by acting as a negative chronotropic and positive inotropic agent, but it is not as effective in situations with high adrenergic activity, such as acute atrial fibrillation.
Making arrangements to have the patient brought to the local emergency department for electrical cardioversion (choice E) is appropriate only after 911 has been called in the case that the patient needs immediate assistance in the office. Without calling 911, the patient may have a seriously adverse event en route to the hospital.
PEARL: Acute onset of atrial fibrillation with a rapid ventricular response is associated with hypotension. The patient may have acute deterioration that would necessitate immediate cardioversion/defibrillation. The patient will need to have volume and airway support given, and management of this patient in an emergency department setting is preferred. Because of the patient rapidly deteriorating, the patient should be transferred to the emergency setting via emergency medical support personnel, who can intervene in case the patient becomes unstable.
