CHF, Atrial Fibrillation, NSTEMI

Tertiary ED. 70F presents in respiratory distress complaining of chest pain. She is found to be in rapid AF of unknown duration as well as CHF. Patient will require analgesia, initiation of afterload reduction with nitroglycerin infusion, respiratory support with bipap, and cautious rate control which improves her vitals and symptoms to a reasonable extent. She will also ultimately require consult to cardiology for consideration of early invasive management given her unstable state.

Goals and Objectives

Education Goal:

• Approach to unstable NSTEMI

Educational:

• Recognition and management of NSTEMI/CHF
• Managing rapid AF of unknown duration in a patient with NSTEMI/CHF
• Use of nitrates, nitroglycerin infusion, and bipap in management of CHF

CRM:

• Effective Communication: Sharing of mental model. For example, explain why you are concerned about heart rate but also about side effects from rate control drugs. Provide clear target goals for your team members.
• Anticipate and Plan: Plan and prepare ahead of time for patient deterioration, i.e., set up art line, call for help early, repeat investigations such as ECG and US/CXR to frequently reassess the patient.
• Distribute the Workload: If you don’t know doses of meds, such as NTG infusion, then delegate someone on your team to look up.