Barriers to Emergency Department Utilization of AFIB Protocol in Uncomplicated Lone AFIB Patients-Results from an Online Survey Study.

BACKGROUND: Historically, atrial fibrillation (AFIB) management has focused on rate control and anticoagulation, necessitating hospital admission. Recently, some emergency departments (EDs) have implemented protocols to avoid hospital admission when managing lone AFIB. Despite this recent trend, there is still reluctance toward the implementation of these protocols by some emergency physicians (EPs). OBJECTIVE: This study investigates barriers to implementation of ED AFIB protocols by surveying which aspects may impede their use. METHODS: To analyze the perceived barriers from EPs, we formulated a survey assessing the various components of ED AFIB management to identify which aspects might impede EP utilization. It was distributed as an email to large national ED physician group. Data was analyzed using descriptive means and weighted averages. RESULTS: Of 185 respondents (response rate 6.1%), 17.4% already had AFIB protocols in place at their home institutions and 82.6% did not. Majority opinion of largest barriers toward the implementation of AFIB protocols were the extended ED length of stay and discharge with unclear follow-up. There was little concern with chemical and electrical cardioversion and very limited concern with rate control and initiating oral anticoagulation. EPs supported placement in Observation for implementation and involvement of discharge planning to establish prescriptions and follow-up. CONCLUSION: EP input regarding the development of ED AFib protocols will be essential in order to develop cost effective, convenient and safe methods of treatment. This survey of EP suggests that ED length of stay and insuring close outpatient follow up are key issues to address as protocols are designed.

Modification of focal cerebral ischemia by cardiac output augmentation.

Intravascular volume expansion has been employed successfully for treatment of ischemic stroke from cerebral vasospasm and from cerebrovascular occlusive disease. The physiologic mechanism responsible for this success has not previously been delineated in controlled experimentation. The objective of this investigation was to delineate the effects of cardiac output and of hemodilution in a primate model of focal cerebral ischemia. Two groups of anesthetized rhesus monkeys received extensive cardiovascular monitoring, and local cerebral blood flow (lCBF) was determined in both ischemic and nonischemic brain regions by the hydrogen clearance method. Both groups were subjected to unilateral middle cerebral artery occlusion. One group then underwent blood volume expansion with Dextran 40 (cardiac output augmentation), and one group underwent isovolemic hemodilution with Dextran 40, cardiac output being maintained constant. Significant increases in lCBF occurred in ischemic regions only and occurred only in response to augmentation of cardiac output. Isovolemic hemodilution failed to produce any changes in lCBF. This investigation indicates that ischemic brain regions are selectively vulnerable to alterations in cardiac output, these effects being independent of alterations in blood pressure. Blood viscosity changes may play only a minor role. This study strongly suggests an important role of intravascular volume expansion and cardiac output augmentation in treatment of acute ischemic stroke.