Atrial fibrillation with RVR - Revision history

Danbot: Add MedicationDose entries (diltiazem, esmolol, metoprolol, amiodarone, magnesium) with SMW annotations

2026-03-20T18:52:03Z

Add MedicationDose entries (diltiazem, esmolol, metoprolol, amiodarone, magnesium) with SMW annotations

@@ Línea 176: / Línea 176: @@
 **Avoid AV nodal blocking agents ([[diltiazem]], [[metoprolol]]) as can lead to [[ventricular fibrillation]]/tachycardia
 **Try to avoid [[cardioversion]] without adequate anticoagulation
 ==Disposition==

Rossdonaldson1: /* Evidence of preexcitation (slurred upstroke of QRS complex, wide QRS complex >120 msec, short PR interval <120msec) */

2022-07-27T21:34:18Z

Evidence of preexcitation (slurred upstroke of QRS complex, wide QRS complex >120 msec, short PR interval <120msec)

← Revisión anterior		Revisión del 21:34 27 jul 2022
Línea 161:		Línea 161:
	\|}		\|}

	===Evidence of preexcitation ~~(slurred~~ upstroke of QRS complex~~, wide~~ QRS complex >120 msec~~, short~~ PR interval <120msec~~)===~~		===Evidence of preexcitation===
	*Avoid AV nodal agents		*Defined as:
			**Slurred upstroke of QRS complex
			**Wide QRS complex >120 msec
			**Short PR interval <120msec
			*Management: '''Avoid AV nodal agents'''
	*Unstable:		*Unstable:
	**[[Synchronized cardioversion]] (120-200 joules for biphasic waveforms, 200 joules for monophasic waveforms)		**[[Synchronized cardioversion]] (120-200 joules for biphasic waveforms, 200 joules for monophasic waveforms)

Djd232: /* Medication Choices */

2021-02-18T16:50:29Z

Medication Choices

← Revisión anterior		Revisión del 16:50 18 feb 2021
Línea 111:		Línea 111:
	\| [[Metoprolol]]\|\|		\| [[Metoprolol]]\|\|
	*Bolus 2.5-5mg IVP over 2min q5min up to 3 doses		*Bolus 2.5-5mg IVP over 2min q5min up to 3 doses
	*If patient responds orally load with 25-50mg		*If patient responds orally load with 25-50mg. The initial oral dose may be estimated based on the IV dose required, based on a 1:2.5 conversion from IV to PO
	\|\|		\|\|
	*Particularly useful when A-fib associated with exercise, after acute [[MI]], or with [[thyrotoxicosis]]		*Particularly useful when A-fib associated with exercise, after acute [[MI]], or with [[thyrotoxicosis]]

Hoxbox: /* Evidence of preexcitation (slurred upstroke of QRS complex, wide QRS complex >120 msec, short PR interval <120msec) */

2021-02-14T12:55:38Z

Evidence of preexcitation (slurred upstroke of QRS complex, wide QRS complex >120 msec, short PR interval <120msec)

← Revisión anterior		Revisión del 12:55 14 feb 2021
Línea 167:		Línea 167:
	*Stable <ref> Page RL et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133(14) </ref>:		*Stable <ref> Page RL et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133(14) </ref>:
	**[[Procainamide]] (17 mg/kg loading dose at 20 to 50 mg/minutes or 100mg every 5 minutes, maintenance infusion 1 to 4 mg/minute) <ref> Neumar RW, Otto CW, Link MS, et al, "Part 8: Adult Advanced Cardiovascular Life Support:2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care," Circulation, 2010, 122:729-67. </ref>		**[[Procainamide]] (17 mg/kg loading dose at 20 to 50 mg/minutes or 100mg every 5 minutes, maintenance infusion 1 to 4 mg/minute) <ref> Neumar RW, Otto CW, Link MS, et al, "Part 8: Adult Advanced Cardiovascular Life Support:2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care," Circulation, 2010, 122:729-67. </ref>
	**[[Ibutilide]] (1mg over 10 minutes, repeat 10 minute infusion can be given)		**[[Ibutilide]] (1mg over 10 minutes, repeat 10 minute infusion can be given)<ref>Dr. Smith's EKG Blog What to do when Atrial Fib with RVR will not Electrically Cardiovert. And how do you measure the QT in Atrial Fib? http://hqmeded-ecg.blogspot.com/2021/02/what-to-do-when-atrial-fib-with-rvr.html</ref>
	**Avoid [[amiodarone]], does not slow accessory pathway and has beta blocking properties, may increase conduction via accessory pathway		**Avoid [[amiodarone]], does not slow accessory pathway and has beta blocking properties, may increase conduction via accessory pathway
	**[[Cardioversion]], consider sedation prior		**[[Cardioversion]], consider sedation prior

Josgood: /* Unstable */

2021-01-25T22:48:37Z

Unstable

← Revisión anterior		Revisión del 22:48 25 ene 2021
Línea 46:		Línea 46:
	**+/- subdissociative pain dosage [[ketamine]] at 15mg		**+/- subdissociative pain dosage [[ketamine]] at 15mg
	*If shock does not work:		*If shock does not work:
	**Verify not preexcitation		**Verify not preexcitation ([[WPW]])
	**Increase diastolic BP to perfuse the heart		**Increase diastolic BP to perfuse the heart
	***		***

Hoxbox: /* External Links */

2020-10-22T19:02:46Z

External Links

← Revisión anterior		Revisión del 19:02 22 oct 2020
Línea 186:		Línea 186:
	*[http://emcrit.org/podcasts/crashing-a-fib/ Crashing Afib - EMCrit]		*[http://emcrit.org/podcasts/crashing-a-fib/ Crashing Afib - EMCrit]
	*Diltiazem load: [[:File:dilt-load.pdf]]<ref>http://ehced.org/wp-content/site/Drips/dilt-load.pdf</ref>		*Diltiazem load: [[:File:dilt-load.pdf]]<ref>http://ehced.org/wp-content/site/Drips/dilt-load.pdf</ref>
			*[http://www.emdocs.net/unstable-atrial-fibrillation-a-guide-to-management/ Unstable Atrial Fibrillation: A Guide to Management from emDocs]

	==References==		==References==

Hoxbox: /* Unstable */

2020-03-02T09:45:35Z

Unstable

← Revisión anterior		Revisión del 09:45 2 mar 2020
Línea 39:		Línea 39:
	**Atrial fibrillation - start at 200 J		**Atrial fibrillation - start at 200 J
	**Atrial flutter - start at 50 J		**Atrial flutter - start at 50 J
			**If you have time sedate with etomidate or ketamine before defibrillation
			***Dose (Etomidate): Start with 0.1mg/kg IV; repeat if needed
			***Dose (Ketamine): Start with 0.5mg/kg IV; repeat if needed
	*Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, altered mental status		*Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, altered mental status
	*Consider cardiostable sedation such as 5mg [[etomidate]]		*Consider cardiostable sedation such as 5mg [[etomidate]]

Rossdonaldson1: /* Disposition */

2020-02-11T21:36:29Z

Disposition

← Revisión anterior		Revisión del 21:36 11 feb 2020
Línea 171:		Línea 171:

	==Disposition==		==Disposition==
			*Admit patients who were unstable
			*Stable and asymptomatic patients can typically be discharged, once controlled
			*Other patients to be determined on a case-by-case basis

	==See Also==		==See Also==

Rossdonaldson1: /* Management */

2020-02-11T21:33:05Z

Management

← Revisión anterior		Revisión del 21:33 11 feb 2020
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	***Ensure baseline magnesium level		***Ensure baseline magnesium level
	***Check magnesium q2hrs if infusing		***Check magnesium q2hrs if infusing

	~~===Stable and Asymptomatic===~~
	~~If mild or no symptoms and pulse only mildly elevated (<110bpm) ok to manage with PO meds~~

	===Stable and Symptomatic===		===Stable and Symptomatic===
Línea 68:		Línea 65:
	*Goal <110bpm		*Goal <110bpm
	**RACE-II trial demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome<ref>Van Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. [http://www.nejm.org/doi/full/10.1056/NEJMoa1001337 full text]</ref>		**RACE-II trial demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome<ref>Van Gelder IC et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. [http://www.nejm.org/doi/full/10.1056/NEJMoa1001337 full text]</ref>

			===Stable and Asymptomatic===
			If mild or no symptoms and pulse only mildly elevated (<110bpm) ok to manage with PO meds

	===[[Cardioversion]]===		===[[Cardioversion]]===

Hoxbox: /* Unstable */

2020-02-04T21:21:51Z

Unstable

← Revisión anterior		Revisión del 21:21 4 feb 2020
Línea 45:		Línea 45:
	**Verify not preexcitation		**Verify not preexcitation
	**Increase diastolic BP to perfuse the heart		**Increase diastolic BP to perfuse the heart
			***
	***Push-dose [[phenylephrine]]		***Push-dose [[phenylephrine]]
	****Will maintain BP when give rate-control meds		****Will maintain BP when give rate-control meds
	****50-200mcg q2-5min with goal ~~DBP >60~~		****50-200mcg q2-5min with goal MAP 70-75
	**[[Amiodarone]] 150mg over 10min (preferably through central venous access) OR [[diltiazem]] 2.5mg/min until HR <100 or max 50mg		***Can also do [[phenylephrine]] as a drip or [[norepinephrine]] drip
	**[[Magnesium]] 2 g over 1-5 min, repeat if no response after 15 min, then consider 1-2 g/h for 4 hrs if response<ref>Kwok MH et al. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta‐analysis. Heart. 2007 Nov; 93(11): 1433–1440.</ref>		**After MAP is better then try to rate control with one of the following
			***[[Amiodarone]] 150mg over 10min (preferably through central venous access) for up to 6 doses OR
			***[[esmolol]] drip (easy to turn off) OR
			***[[diltiazem]] infusion 2.5mg/min until HR <100 or max 50mg
			**[[Magnesium]]
			***Be careful since can worsen vasodilation for these hypotensive patients
			***2 g over 1-5 min, repeat if no response after 15 min, then consider 1-2 g/h for 4 hrs if response<ref>Kwok MH et al. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta‐analysis. Heart. 2007 Nov; 93(11): 1433–1440.</ref>
	***Significantly less effective than [[amiodarone]] or [[calcium-channel blockers]]		***Significantly less effective than [[amiodarone]] or [[calcium-channel blockers]]
	***Ensure baseline magnesium level		***Ensure baseline magnesium level