![]() Ketamine dissociation is a solid option.Etomidate may be a good choice to achieve deep sedation briefly.Sedative regimen will vary depending on context (e.g., many patients may already be deeply sedated).Consequently, the mainstay of patient comfort is deep sedation. For example, no reasonable dose of opioid will make cardioversion comfortable. Intravenous magnesium should also be considered (more discussion of this below).Amiodarone may subsequently be continued until the patient has recovered from their critical illness (e.g., for 1-2 weeks). Pre- and post-treatment with amiodarone may promote successful and sustained cardioversion.For example, DC cardioversion will often transiently elicit normal sinus rhythm, with a subsequent reversion into atrial fibrillation. Among critically ill patients, DC cardioversion alone usually fails to achieve sustained sinus rhythm.Pre & post-treatment with anti-arrhythmic How to perform electrical cardioversion for atrial fibrillation or flutter in critical illness If a patient with AF and an accessory pathway is displaying instability, proceeding directly to DC cardioversion is indicated. This is a unique situation where DC cardioversion is usually the treatment of choice (based on its efficacy and speed).Antiarrhythmics which may be used are procainamide or ibutilide. Blockade of the AV node may merely cause a greater dominance of the accessory pathway, exacerbating matters (to a certain extent, the AV node and the accessory pathway are competing for control of the ventricle). beta-blockers, calcium channel blockers, or amiodarone). AF with an accessory tract shouldn't be treated with medications that impair the AV node (eg.Morphology varies between different beats (some beats are fusion complexes if the AV node and the accessory pathway fire at a similar time).Wide-complex beats can result from transmission over the accessory pathway.Irregularly irregular heart rate that may be extremely fast (e.g.AF with an accessory pathway produces a fairly distinctive pattern of EKG findings:.This is dangerous because the extremely fast and uncoordinated contractions of the ventricle can promote ventricular tachycardia or cardiovascular collapse. (1) Heart rate: As a general rule, heart rates 200).Some key pieces of information can help:.The key question is: What is driving the instability? Is the atrial fibrillation causing the patient to be unstable? Or is atrial fibrillation merely triggered by underlying instability?.How much is AF actually contributing to the patient's instability? TSH should be considered if there is no obvious cause of AF, or if other clinical features suggest thyrotoxicosis.If there is other evidence suggesting PE, CT angiography may be indicated.If thoughtful review of EKG and history suggests ischemia, then obtain troponin.Additional tests as clinically warranted.Review of the presence of any indwelling cardiac devices.Pneumonia, COPD, hypoxemia, hypercapnia.Primary neurologic disorders (e.g., intracranial hemorrhage, ischemic stroke). ![]()
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