Slide 1: You are called to the bedside of your COVID-19 ICU patient for tachycardia. What’s the rhythm?

Slide 2: Is it “fib” or flutter? Let’s look for typical flutter findings. EKG showing “saw-tooth” atrial flutter activity best seen in lead two, lead three, and aVF. Flutter waves should be regular (ventricular response can be variable). Each flutter wave should appear the same. Therefore, the diagnosis is atrial fibrillation. Coarse Afib suggests new-onset or paroxysmal.

Slide 3: For new Afib think of P-I-R-A-T-E-S, pirates, for secondary causes. P stands for pulmonary disease or embolism, such as pneumonia, COPD, or OSA. I stands for ischemia or infarct. R stands for rheumatic heart disease or other mitral pathology. A stands for anemia. T stands for thyrotoxicosis. E stands for ethanol, electrolytes, or other ingestions such as cocaine or amphetamines. S stands for sepsis or infections/inflammatory state.

Slide 4: Suggested wuorkup. Labs. Low potassium or magnesium? CMP and magnesium. Anemia? CBC. Hypo or hyperthyroidism? TSH/FT4, etc. Imaging. Lung disease, pulmonary edema, or cardiomegaly? Structural heart disease? Chest radiograph and transthoracic echocardiogram. In COVID-19, pneumonia, sepsis, anemia, etc. all place patients at a higher risk of new onset Afib.