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 (4.01).
• Hypoxia, INITIAL MEDICAL CARE (2.01).
• Toxic effects of medications or alcohol.
• Thyroid Disease.

STABLE:

• INITIAL MEDICAL CARE (2.01) - OXYGEN @ 100% via NRB mask or assist with BVM.
• If rate is greater than 150 beats/minute and narrow complex. Administer DILTIAZEM (CARDIZEM) 0.25 mg/kg IV bolus over 2 minutes. If no response in 30 minutes and heart rate greater than 150, 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 PARAMETER (4.10)
• ASPIRIN 81mg, chewed, if not previously administered or with known hypersensitivity to the drug or active ulcer disease.

BLACK BOX WARNING: 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 CARE (2.01)- OXYGEN @ 100% via NRB mask or assist with BVM.
• O2 saturation, monitor in place.
• SYNCHRONIZED CARDIOVERSION @ 50 Joules.
• Consider pre-medication with 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/SEDATION PARAMETER (2.04)
• If NO response, SYNCHRONIZED CARDIOVERSION @ 100 Joules.
• If NO response, SYNCHRONIZED CARDIOVERSION @ 200 Joules.
• If NO response, 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 should be administered.