Atrial fibrillation or atrial flutter

Question 1

If the patient is not compromised or is mildly compromised

Answer 1

Do not provide specific treatment for the dysrhythmia.

Question 2

If the patient is moderately compromised

Answer 2

• Administer 300 mg of amiodarone IV over approximately 30 minutes, provided the patient’s systolic BP is greater than 100 mmHg.
• Administer a further 150 mg of amiodarone IV over approximately 30 minutes, using the same indications if the patient remains in atrial fibrillation or atrial flutter.
• Use amiodarone with caution if the patient is poorly perfused and reduce the rate of administration if there is a significant fall in blood pressure.

Question 3

If the patient is severely compromised

Answer 3

• Reconsider the diagnosis because it is very rare for atrial fibrillation or atrial flutter to cause severe compromise.
• If the patient can obey commands:
  a) Gain IV access, administer 1 mg/kg of ketamine IV (up to a maximum of 100 mg) to induce dissociation, and
  b) Cardiovert using maximum joules in synchronised mode. Repeat this once if the rhythm fails to revert.
• If the patient cannot obey commands:
  a) Cardiovert using maximum joules in synchronised mode. Repeat this once if the rhythm fails to revert, or
  b) Attach and use a defibrillator in automatic mode if you cannot use it in manual mode.

Question 4

Atrial fibrillation is commonly associated with

Answer 4

severe sepsis and/or high grade fever, particularly in the elderly.

Question 5

Amiodarone should only be administered in the setting of sepsis if the patient is

Answer 5

normotensive, the ventricular rate has failed to settle with 0.9% sodium chloride IV and cooling, and the patient has significant symptomatic myocardial ischaemia.

Question 6

Cardioversion checklist

Answer 6

• Place pads in either the apex/sternum (recommended) or anterior/posterior position, in addition to ECG electrodes.
• Ensure the defibrillator is in manual mode.
• Select a lead with a visible R wave and ensure that artefact is minimised.
• Select synchronised mode.
• Confirm there are detection symbols with most QRS complexes.
• Ensure the patient has received adequate sedation if indicated.
• Select maximum joules, charge the defibrillator and confirm everyone is clear.
• Press and hold the shock button until the shock is delivered.
• Determine the rhythm and reassess vital signs.
• If administering a second cardioversion, confirm the defibrillator is still in synchronised mode and the patient is adequately sedated.