Sandbox/Afib

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

New onset atrial fibrillation: ❑ The presentation can be any of the following: ❑ Paroxysmal and stop spontaneously ❑ Persistent and stop only with cardioversion ❑ Permanent and present for prolonged periods

Asymptomatic

Mild to moderate symptoms

Unstable: ❑ Hypotension ❑ Tachycardia ❑ Cold extremities ❑ Peripheral cyanosis ❑ Mottling ❑ Altered mental status ❑ Ongoing ischemia ❑ Decompensated heart failure

Identify the underlying etiology and treat accordingly

Does the patient have any evidence of an accessory pathway (per-exitation syndrome)

Does the patient has any symptoms and signs of pulmonary edema? ❑ Dyspnea ❑ Crackles ❑ Chest X-ray showing pulmonary edema

Proceed with cardioversion strategy

No

Yes

Yes

No

Does the patient has any evidence of heart failure

❑ DC cardioversion ❑ IV procainamide or amiodarone when urgent cardioversion is not available or recommended

Manage pulmonary edema: ❑ Initiate oxygen therapy ❑ High doze IV diuretics ❑ BP management ❑ SBP 85 - 100 mm Hg (dobutamine or milrinone) ❑ SBP < 85 mm Hg (dopamine and norepinephrine)

Immediate DC cardioversion

Yes

No

After initial pulmonary edema management proceed with DC cardioversion

Heart rate control: ❑ Digoxin ❑ Oral vs intravenous are based upon the clinical urgency

Heart rate control: ❑ Beta blockers or CCB's ❑ Oral vs intravenous are based upon the clinical urgency

Successful

Unsuccessful

Does the patient respond or the arrhythmia terminate?

Identify the underfying cause and treat accordingly

Repeated attempts may be made after adjusting the location of the electrodes or applying pressure over the electrodes, or following administration of an antiarrhythmic medication

Yes

No

Identify the other underlying etiologies and treat accordingly

Oral vs intravenous amiodarone according to the clinical urgency

Proceed with the cardioversion strategy

Does the patient respond or the arrhythmia terminate?

Yes

No

Proceed with the cardioversion strategy

DC cardioversion

References

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