Atrial Fibrillation 心房顫動抗凝血藥物使用

Thromboembolism Prevention 判斷是否需使用抗血栓藥物原則 (ACC/AHA/HRS guidelines 2019 focus update/2014)

* AF(Atrial fibrillation) 與 Atrial flutter 原則上當作相同方式處理

Class I 建議 (2014 guideline)

1. 當AF or atrial flutter 持續超過 48-hour 或者不知持續時間時，不管CHA2DS2-VASc score多高，Warfarin(控制在INR 2.0 ~ 3.0) 建議在轉回正常心律前(不管藥物或電擊)，建議至少需使用3週，且之後持續使用4週。(2019 guideline, NOACs並不比Warfarin差)

2. 當AF or atrial flutter 持續超過 48-hour 或者不知持續時間時需立即做Cardioversion時，抗凝血藥物需盡早使用，且持續至少4週。

3.當AF or atrial flutter 少於48-hour且有中風高風險時，intravenous heparin or LMWH或者factor Xa or direct thrombin inhibitor，建議盡早使用，且應長期使用。

4. 在轉回竇性心律後，長期使用抗凝血藥物的使用，應根據血栓形成的風險做評估‧

Class IIa 建議 (2014 guideline)

1. 當AF or atrial flutter 持續超過 48-hour 或者不知持續時間，且之前3週沒有接受抗凝血藥物治療，在Cardioversion前做TEE是合理的，確定LA(包含LAA)沒有血栓，且應在TEE之前使用抗血栓藥物及在轉回竇性心律後使用至少4週。

2. 當AF or atrial flutter 持續超過 48-hour 或者不知持續時間時， 抗凝血藥物dabigatran, rivaroxaban, or apixaban在轉回正常心律前(不管藥物或電擊)使用3週，且之後持續使用4週是合理的(reasonable)。

Class IIb 建議(2014 guideline)

1. 當AF or atrial flutter 少於48-hour且血栓形成低風險時, 使不使用抗凝血藥物都是合理的(reasonable)。

2019 Focused update: 

1. CHADVASc score: men 2, women 3 建議使用口服抗凝血藥物。

2. NOACs比起Warfarin並不更差，且在某些trial勝過Warfarin。

3. INR穩定前，應至少每週評估，穩定後至少每月評估。

4. 不論是Paroxysmal, persistent, permanent pattern的心房顫動，都應根據血栓形成風險使用抗凝血藥物。

完整文章請參考2019/2014 AHA/ACC/HRS guideline

Ref:

1. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000665

2. https://www.ahajournals.org/doi/10.1161/cir.0000000000000041

值班常用藥物 Medication

DKA (Diabeteic ketoacidosis)

Insulin (100 U regular insulin in 100 mL NS) run at 0.1 U/kg/h, keep glucose > 250 mg/dl 

If K<3.5, may postpone insulin until K>3.5 mEq/L

Ref:

Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5TH EDITION

Atrial fibrillation

Rhythm control:  

- Amiodarone: 

 - 5–7 mg/kg over 30–60 min, then 1.2–1.8 g/d continuous infusion or in divided PO doses until 10 g total   - 600–800 mg/d divided dose until 10 g total, then 200–400 mg/d maintenance 

Rate control:

Antithrombotic therapy( If duration>48hrs, or not sure)

- Heparin: Load 80 U/kg IV; infusion at 18 U/kg/h. 

- Low-molecular-weight heparin: 1 mg/kg SC BID 

- Warfarin sodium: 2.5–5 mg/d PO, (based on INR)

- Aspirin: 50–325 mg/d 

- DOAC(dabigatran, rivaroxaban, apixaban, and edoxaban)

Ref:

1. Rosen & Barkin’s 5-Minute Emergency Medicine Consult 5TH EDITION

2. 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation

插管用藥整理 Intubation medication

插管用藥
Midazolam (Dormicum)	Onset: 60-90 sec Duration: 1~4 hours Dose: 0.1-0.3mg/kg IV	Pros:   Cons: hypotension
Ketamine	Onset: 30 sec Duration: 5~15min Dose: 1-2 mg/kg IV	Pros: For shock, pain control, brochodilation Cons: ICP↑、CO↓
Etomidate	Onset:15-45 sec Duration:3~12min Dose: 0.3mg/kg IV	Pros: For shock, ICP↓ Cons: Adrenal suppression
Propofol	Onset: 15-45 sec Duration: 5~10min Dose: 1-2mg/kg IV	Pros: ICP↓, Seizure control, bronchodilation Cons: hypotension, propofol infusion syndrome
Thiopental	Onset: 30 sec Duration: 5~10min Dose: 3-5mg/kg IV	Pros: ICP↓, Seizure control Cons: hypotension, bronchospasm

急性代償性心臟衰竭處理 Acute Decompensated Heart Failure Management

臨床評估 Clinical evaluation

初始治療 Initial therapy

#監測生命徵象、心律
Monitor oxygen saturation, vital signs, and cardiac rhythm.

#給氧氣、建立靜脈通路、維持病人挺直坐姿
Provide supplemental oxygen if hypoxic (SpO2 <90%), place 2 IV catheters, and position patient upright.

Provide NIV as needed, unless immediate intubation is required or NIV is otherwise contraindicated; have airway management equipment readily available;

#利尿劑需盡快給予不能拖延，在鬱血性心臟衰竭及體液過多的病人
Initiate diuretic therapy without delay to relieve congestion/fluid overload:

*起手式
1.過去沒使用過利尿劑的病人可以Furosemide 40mg IV(2支)、bumetanide 1mg IV(半支)
2.長期慢性使用利尿劑或腎臟衰竭的病人可能需要用到平常的2倍劑量

#尋找造成急性代償心臟衰竭 (ADEF)的原因並給予相應性的治療，包含 Acute coronary syndrome, Hypertension, Arrhythmia, Acute aortic or mitral regurgitation, Aortic dissection, Sepsis, Renal failure, Anemia, or Drugs

 #心律過快及心房顫動的狀況考慮使用毛地黃digoxin控制心律
Patients with ADHF and AF with rapid ventricular rate often require medication (eg, digoxin) to slow their heart rate.

#若心房顫動合併血液動力學不穩需考慮使用電擊整流
Direct current cardioversion is indicated for patients with new onset AF and hemodynamic instability or refractory symptoms despite rate control.

#在急性主動脈瓣或二尖瓣迴流或升主動脈剝離病人需照會心臟外科處理
Obtain immediate cardiac surgery consultation for acute aortic or mitral regurgitation or ascending aortic dissection.

#End-organ perfusion充足狀況下考慮使用Vasodilator治療
For patients with adequate end-organ perfusion (eg, normal or elevated blood pressure) and signs of ADHF with fluid overload:

*嚴重高血壓、急性主動脈瓣或二尖瓣迴流(Undercircumstances of Severe HTN, MR, AR)考慮使用Nitoprusside
Nitroprusside: 5 to 10 mcg/min and titrate up every 5 minutes as tolerated to a dose range of 5 to 400 mcg/min

*利尿劑使用下仍不足的狀況下考慮使用IV NTG(Undercircumstances of inappropriate diuretics therapy response)
Nitroglycerin(NTG): 5 to 10 mcg/min and titrate every 3 to 5 minutes, range: 10 to 200 mcg/min.

#收縮性心臟衰竭併發ADEF停止beta-blocker使用，嚴重的ADHF或心因性休克，使用IV inotrope，例如 dobutamine或 milrinone (Primacor)，或考慮使用 IABP (Intraaortic balloon counter pulsation)

#LVOT狀況下考慮使用 beta blocker，若有肺水腫考慮使用針劑型利尿劑 ，給予IV vasopressor (eg, phenylephrine or norepinephrine); 禁止給予強心劑或血管舒張劑

#不知心臟狀況之下若有嚴重ADEF且合併心因性休克，給予IV強心劑(eg, dobutamine or milrinone), 給予或不給予IV血管收縮劑(eg, norepinephrine)，並且考慮 Mechanical support如IABP (Intraaortic balloon counter pulsation)

*各種心因性休克病因下之血管收縮作用劑使用選擇 (Circulation, 2017)

Cause or Presentation of CS	Vasoactive Management Considerations
Classic wet and cold	Norepinephrine or dopamine Inotropic agent
Euvolemic cold and dry	Norepinephrine or dopamine Inotropic agent Small fluid boluses
Vasodilatory warm and wet or mixed cardiogenic and vasodilatory	Norepinephrine Consider hemodynamics-guided therapy
RV shock	Fluid boluses Norepinephrine, dopamine, or vasopressin Inotropic agents, Inhaled pulmonary vasodilators
Normotensive shock	Inotropic agent or vasopressor
Aortic stenosis	Phenylephrine or vasopressin In patients with reduced LVEF, echocardiography- or PAC-guided dobutamine titration
Aortic regurgitation	Dopamine Temporary pacing
Mitral stenosis	Phenylephrine or vasopressin Esmolol or amiodarone
Mitral regurgitation	Norepinephrine or dopamine Inotropic agents Temporary MCS, including IABP
Postinfarction ventricular septal defect	See classic wet and cold considerations Temporary MCS, including IABP
Dynamic LVOT obstruction	Fluid boluses, Phenylephrine or vasopressin, Avoid inotropic agents, Avoid vasodilating agents, Esmolol or amiodarone RV pacing
Bradycardia	Chronotropic agents or Temporary pacing
Pericardial tamponade	Fluid bolus Norepinephrine

Ref:
1.Treatment of acute decompensated heart failure: Components of therapy
https://www.uptodate.com/contents/treatment-of-acute-decompensated-heart-failure-components-of-therapy
2.Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association, Circulation. 2017;136:e232–e268. DOI: 10.1161/CIR.0000000000000525