The normal rhythmic movement of the heart is what helps efficiently pump blood to the various tissues and organs of the body. The contraction of these cardiac muscles pumping oxygen-rich blood through our bodies are what keep us alive. However, it is possible for these muscles to become unsynchronized, compromising its function and its ability to keep us alive. Unfortunately for most this dysfunction occurs at the most inopportune of times, leaving those affected to either live or die depending on the speed of treatment and the effectiveness of medications employed at the time of the cardiac event. Having the knowledge of how to approach a person facing a potentially fatal cardiac event is imperative for their survival. Often, it is a race against time in these situations and following proven lifesaving procedures can make all the difference.
We will address atrial flutter management and discuss various atrial flutter treatment guidelines outlined by A Flutter treatment ACLS (Advanced Cardiac Life Support) protocol. We will also discuss various atrial flutter medications used for atrial flutter treatment, how to recognize the various atrial flutter symptoms and discuss atrial flutter ECG interpretation to give a better understanding of this potentially fatal cardiac condition.
Classified under as a type of Supraventricular Tachycardia (increased heart beats originating above the ventricles), Atrial flutter is an abnormal heart rhythm causing the heart to beat out of sync from the normal physiological heart rate of 60-100 beats per minute. Considered the second most common tachyarrhythmia after atrial fibrillation, atrial flutter causes the heart to beat at a rate of between 200-350 beats per minute resulting in a narrow complex tachycardia. A normal heart rate is required for adequate pumping of blood to the rest of the body, and if this does not occur, severe long-term consequences such as ischemia and cardiac arrest are more likely to ensue. Due to the irregular rate of contraction in the atria, while the ventricles are relaxing, decreased amounts of blood is effectively pushed to the rest of the heart to be pumped back into circulation, compromising the vital function of the heart muscle.
The heart is comprised of four chambers, the upper right and left atria, and the lower right and left ventricles. Under normal physiologic conditions, an electrical signal is sent from the Sino arterial node (SA node) located in the right atrium. This signal propagates out to both atria at a very fast speed which allows them to contract at approximately the same time. That original signal then travels to the atrial-ventricular node (AV node) down to the ventricles which allow them to contract shortly after. The ventricles have to wait for another signal for them to contact again, following a short refractory period. In atrial flutter, however, a reentry rhythm causes this signal to loop back on itself in a circular pattern not allowing the signal to reach the ventricles for contraction as intended, but instead stay confined to the atria, causing them to contact again and again in a wavelike pattern similar to a flapping or fluttering motion. A reentry refractory signal eventually makes its way to the ventricles after the AV nodal refectory period has expired allowing them to contract once again.
Atrial flutter results in an AV conduction ratio of 2:1, 3:1, or even 4:1 represented on an atrial flutter ECG, owing to an innate regulating effect of the AV node and AV bundle to normally control excessively high heart rates by having a refractory period where no signals can be transmitted; a conduction block. This can be appreciated as the atria beat at a very high rate, for example, the atria may beat at 300bps, but the ventricles are prevented from contracting as quickly and only beat at about 150bpm owing to the AV node’s refractory period. This means there are more atrial contractions that occur before the ventricles even have a chance to contract which can be seen on atrial flutter ECG tracings. A Flutter treatment often revolved around correcting this rhythmic aberration of the atria, with the body being able to somewhat counteract the abnormality to the best of its ability, as the ventricles are the main contributor to cardiac output.
While atrial flutter can affect virtually anyone, typically persons displaying certain risk factors are more prone to developing the condition. Individuals suffering from a previous cardiovascular disease stemming from conditions such as uncontrolled high blood pressure, previous heart attack, and valvular disease are just some of the causes that may predispose one to develop atrial flutter. Another possible origin comes in the form of a premature atrial contraction (PAC), which is an electrical impulse that is sent out earlier than normal in the atrium and has a relatively unknown cause for its occurrence. Atrial flutter symptoms can be subjective and can vary from person to person with some individuals not experiencing any symptoms at all, but typically the most common atrial flutter symptoms include an increased pulse rate, shortness of breath, dizziness and/or fainting, and the sensation of tightness or pain in the chest with some patients having a feeling of impending doom. Much like most rhythm disorders of the heart, stagnate blood or pooling of blood can become a serious problem leading to clot and embolus formation, which have the potential to travel to the brain causing a stroke which is why typically atrial flutter medications include an anticoagulant or blood thinner to prevent these clots from ever forming, often rounding out typical atrial flutter treatment.
Without proper A Flutter treatment, over time the condition may progress to atrial fibrillation or even heart failure leading to more serious consequences.
An electrocardiogram (ECG) is often one of the first steps for the diagnosis of atrial flutter. Using electrodes placed on the patient’s chest, physicians can accurately determine the electrical activity of the heart over a period of time, recording the heart muscle’s electrophysiological pattern to determine if any abnormalities are depicted. Consisting of P waves, QRS complexes, and T waves, representing atrial depolarization, ventricular depolarization, and ventricular repolarization respectively, a properly executed ECG can be an invaluable tool for diagnosing and providing A Flutter treatment to patients.
In the case of A Flutter ECG tracings, since there is an abnormality located near the SA and AV nodes in the atrium, you will expect to see multiple spiking P waves with a regularly spaced QRS complex on an A Flutter ECG. These multiple P waves are due to the over firing of impulses contracting the atria which eventually reach the ventricles after the AV node refractory period has ended, often leading to the AV conduction ratios previously mentioned. For example a 3:1 conduction ratio implies that 3 P wave formations are seen before every 1 QRS complex. This P wave formation often makes a classic pattern that resembles the teeth on a saw, which helped coined the term “saw-toothed” appearance for an A Flutter ECG tracing.
Most patients suffering from atrial fibrillation tend to tolerate minor symptoms well when on a controlled A Flutter treatment plan. Atrial flutter medications to control heart rate to more normal levels include likes of beta blocker and calcium channel blockers. However, in unstable patients, those who are currently experiencing chest pain, decreased blood pressure (hypotension), or altered mental status, it is inadvisable to use such medications for A Flutter treatment in these cases.
Based on the advice of a medical professional, patients in unstable conditions may require immediate use of a synchronized DC cardioversion or a controlled electrical shock with a defibrillator under anesthesia with a recommend initial shock dose of 50-100J (biphasic device), which essentially depolarizes all the atrial tissue at the same time allowing the sinus node to once again take control; a normal sinus rhythm. While effective in about 90% of patients, some, however, revert back to atrial flutter and may benefit from more invasive measures of A Flutter treatment.
Advanced cardiac life support protocol was developed to give health care professionals the skills and knowledge of particular clinical interventions for the urgent treatment of cardiac arrest, stroke, and other life-threatening medical emergencies. It requires the ability to read and interpret ECGs, manage a person’s airway, provide IV access, and have knowledge of the particular drugs and medications utilized. Knowledge of basic life support (BLS) is also required as advanced cardiac life support is built on its core foundation, which includes cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use. Studying the ACLS tachycardia algorithms for managing stable and unstable tachycardia will make it much easier for those looking to score well on your ACLS pretest answers score sheet.
A Flutter treatment follows the ACLS protocol for managing tachycardia patients; patients with >100bpm. While generally a heart rate of 100-150bpm is most likely caused by an underlying process resulting in a sinus tachycardia, due to such instances of anxiety, dehydration or even exercise, with patients being stable, relatively speaking. Minimal to no symptoms are often seen during sinus tachycardia’s and can be corrected by treating the underlying cause or with vagal maneuvers and/or heart rate stabilizing medications while monitoring an ECG to observe whether that patient has returned to a normal sinus rhythm, if necessary.
In cases where the heart rate has reached a higher threshold of >150bpm, often resulting from some pathology, patients tend to be symptomatic and benefit greatly from atrial flutter guidelines set by ACLS for tachycardia. The higher the heart rate the more likely the symptoms are a result of the tachycardia, requiring more extreme measures needed to be employed to give the patient the highest rate of survival possible using specific A Flutter treatment. The following is a step by step algorithm developed to assist individuals with stable and unstable tachycardia with a pulse (patients without a pulse should follow the Pulseless Electrical Activity (PEA) algorithm).
1. Patient Assessment
a. Check airway, breathing, and circulation; intubate if necessary
b. Give oxygen if oxygen saturation is <94%, or the patient is short of breath
c. Perform a 12 lead ECG if the patient is stable
d. Identify rhythm
e. Check blood pressure
f. Identify and treat reversible causes
2. If the Patient is Unstable
Identifying if an individual is stable or not can be tricky but looking for certain signs and symptoms will give you a good idea whether they are or not. Checking for decreased blood pressure (hypotension, a) Start an IV
b) If the patient is conscious, sedate
c) Immediate synchronized cardioversion (Narrow regular rhythm typically found in A Flutter = 50-100J)
d) Consider expert consultation
Electrical shock therapy should convert the patient back into sinus rhythm, and at this point should be monitored closely for any reoccurrence. It is also advisable to look for any of the causes of the atrial flutter and be treated as soon as possible.
3. If the Patient is Stable
A patient is considered stable if they are devoid of all the aforementioned unstable symptoms.
a) Start IV
b) Obtain a 12-lead ECG for QRS interpretation
a) Narrow ( b) Regular rhythm – Give Adenosine 6mg rapid IV push
c) Repeat 12mg dose once if necessary
Once these steps are implemented, observing whether the patient converts back to a normal sinus rhythm is paramount. If it does, it confirms that the rhythm originated from the atria as conversion with Adenosine is considered diagnostic, and at this point, it is advisable to watch the patient for any reoccurrence. If the tachycardia reoccurs, treat with adenosine or longer acting AV nodal blocking agents, such as a beta-blocker or calcium channel blocker in these stable patients.
The A Flutter treatment options outlined above are generally the typical Atrial Flutter management used for long term regulation, with the exception of Adenosine. Atrial flutter guidelines also dictate the use of anticoagulation therapy as warranted post cardioversion, as immediately after a shock blood flow velocity to distal organs and extremities are at its lowest . A Flutter episodes for an uncertain duration or >48 hours absolutely require the use of anticoagulation therapy for a minimum of four weeks or at least until sinus rhythm is maintained. It is suggested as a first-line therapy to use catheter radiofrequency ablation for atrial flutter patients fitting certain criteria (cavotricuspid-isthmus-dependent flutter), as the success rate for complete resolution of symptoms ranges from 90-95%. This A Flutter treatment method of ablation is achieved by physically destroying the reentrant circuit that is the origin of the disorder, effectively curing patients, relieving them of any further atrial flutter management.