View source for Atrial Fibrillation Atrial Flutter

==Section 4 - CARDIAC==
===4.03 ATRIAL FIBRILLATION / ATRIAL FLUTTER===

'''CONSIDER MEDICAL ETIOLOGY AND REFER TO APPROPRIATE PRACTICE PARAMETER:'''
* [[Chest Pain Acute Coronary Syndrome|CHEST PAIN / ACUTE CORONARY SYNDROME]] (4.01).
* Hypoxia, [[Initial Medical Assessment and Care|INITIAL MEDICAL CARE]] (2.01).
* Toxic effects of medications or alcohol.
* Thyroid Disease.

==== STABLE: ====
* [[Initial Medical Assessment and Care|INITIAL MEDICAL CARE]] (2.01) - [[Medical Gases|OXYGEN]] @ 100% via NRB mask or assist with BVM.
* If rate is greater than 150 beats/minute and narrow complex. Administer [[Antiarrhythmics|DILTIAZEM (CARDIZEM)]] 0.25 mg/kg IV bolus over 2 minutes. If no response in 30 minutes and heart rate greater than 150, [[Antiarrhythmics|DILTIAZEM (CARDIZEM)]] 0.35 mg/kg IV bolus over 2 minutes
* If rate greater than 150 beats/minute and wide complex refer to [[Wide Complex Tachycardia Uncertain Origin|WIDE COMPLEX TACHYCARDIA PARAMETER]] (4.10)
* [[Salicylates|ASPIRIN]] 81mg, chewed, if not previously administered or with known hypersensitivity to the drug or active ulcer disease.

'''''BLACK BOX WARNING: [[Antiarrhythmics|DILTIAZEM (CARDIZEM)]] IS CONTRAINDICATED IN HYPOVOLEMIA AND CALCIUM CHANNEL BLOCKER USE.'''''
'''''Use in these situations can result in severe bradycardia and refractory hypotension or cardiac arrest.'''''

==== UNSTABLE: ====
* [[Initial Medical Assessment and Care|INITIAL MEDICAL CARE]] (2.01)- [[Medical Gases|OXYGEN]] @ 100% via NRB mask or assist with BVM.
*O2 saturation, monitor in place.
* [[Cardioversion|SYNCHRONIZED CARDIOVERSION]] @ 50 Joules.
*Consider pre-medication with [[Sedative Hypnotics|MIDAZOLAM (VERSED)]]. Start at 2-5 mg then 2 mg every 30 seconds to 1 min IVP or IN if patient is conscious.
*May repeat as necessary to allow for sedation. See [[Analgesia and Sedation|ANALGESIA/SEDATION PARAMETER]] (2.04)
* If NO response, [[Cardioversion|SYNCHRONIZED CARDIOVERSION]] @ 100 Joules.
* If NO response, [[Cardioversion|SYNCHRONIZED CARDIOVERSION]] @ 200 Joules.
* If NO response, [[Cardioversion|SYNCHRONIZED CARDIOVERSION]] @ 300 Joules.


'''''Physician's Orders: If NO response, contact Medical Control for consult.'''''

This Standing Order is divided between the care and treatment of the stable patient verses the unstable patient. As a matter of definition agreed upon by the Medical Directors, the UNSTABLE patient is one who presents with any of the following: '''''SIGNIFICANT CARDIAC SYMPTOMS, SIGNIFICANT DYSPNEA, ALTERED MENTAL STATUS, OR HYPOTENSION WITH SIGNS OF DECREASED TISSUE PERFUSION, OR SIGNIFICANT COMPROMISE OF AIRWAY, BREATHING AND/OR CIRCULATION.'''''

'''''If there is a prolonged delay or difficulty obtaining synchronization, and the patient is extremely UNSTABLE, then [[Defibrillation|DEFIBRILLATION]] should be administered.'''''

[[Category:Cardiac|0403]]