The EM Educator Series: Not-your-straightforward Atrial Fibrillation

Author: Alex Koyfman, MD (@EMHighAK) // Edited by: Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER)

Welcome back to the EM Educator Series. These posts provide brief mini-cases followed by key questions to consider while working. The featured questions provide important learning points for those working with you, as well as vital items to consider in the evaluation and management of the specific condition discussed.

This week has another downloadable PDF document with questions, links and answers you can share with learners as educators in #MedEd. Please message us over Twitter and let us know if you have any feedback on ways to improve this for you. Enjoy!

Case #1:

A 46-year-old male presents with palpitations for three hours. He is otherwise hemodynamically stable and appears well. He has known hypertension, but no other known conditions. ECG demonstrates irregularly irregular rhythm at 142 beats per minute.

Case #2:

A 79-year-old female is brought from the nursing home for fever, cough, and altered mental status. She has a history of hypertension, diabetes, prior stroke, and hyperlipidemia. Her VS include BP 87/51, HR 132, Sats 90% on RA, Temp 101.2 oral. Her ECG reveals an irregularly irregular rhythm consistent with her known atrial fibrillation at a rate of 133 beats per minute.


  • What are triggers for atrial fibrillation? What about AF with RVR?
  • Is there utility for bedside ultrasound in AF with RVR?
  • When should you use a calcium channel blocker versus beta blocker?
  • What do you need to consider in the sick, hypotensive patient with AF and RVR? Doesn’t the patient just need rate control?
  • When and how do you cardiovert these patients? Why does cardioversion fail?
  • Is measuring a troponin needed? If so, when?
  • What is concerning for WPW with AF?

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