Crashing AFib patient
Tachy, hypotensive
[ ] pre-med: Etomidate 5-7 mg, Ketamine 10-15 mg, or Fent 25-50
[ ] sync 200 J
If wide QRS and rate >250 it's WPW. Shock, shock.
Still hypotensive?
[ ] Phenylephrine 50-200 mcg/min
[ ] Amio 150 bolus f/b gtt or
[ ] Dilt 2.5 mg/min titrate up until HR < 100
[ ] Consider Ca++ (to boost BP) and Mag++ for (excellent rate/rhythm control)
Merely Rapid AFib
[ ] No signs of embolic disease
- neuro exam, inspect hands & feet
[ ] TSH, Dig level
[ ] ASA 325
[ ] IV nodal agent (Dilt 0.25 mg/kg, Metoprol 5 mg, or Verapamil
- If IV treatment works, f/b Dilt 30-60 mg PO, or Metoprolol 50 mg PO or Sotalolol 80 mg PO
- or Dilt gtt @ 5-10 mg/h (up to 15 mg/h)
- or Esmolol gtt 500 mcg/kg/min load, f/b gtt 50 mcg/kg/min titrate by 50s to goal
- or Amiodarone 5 mg/kg IV over 30 min; or 300 mg PO; f/b gtt 1 mg/kg
CHADS score
New Onset AFib Ottawa Protocol
WPW and Rapid A Fib? Be Wary of ACLS
Amiodarone has AV nodal blockade properties; it can have proarrhythmic effects in rapid atrial fibrillation with WPW because it can accelerate the ventricular rate and has been documented to precipitate ventricular fibrillation (4).