Decision
Are any of the following present?
- Wide, bizarre QRS
- History of Wolff-Parkinson-White syndrome
- Delta wave on ECG
- Ventricular rate >220 beats/min
Yes
- Perform synchronized cardioversion (Class I) with sedation, if hemodynamically unstable
- Medication
- Procainamide 100 mg IV q5-10 min, max 17 mg/kg (Class I)
- Amiodarone 150 mg IV over 10 min (Class III)
IF rate <100 beats/min and normotensive without requiring additional IV medication:
- Discharge with 24-hr cardiology or ED follow-up
- Anticoagulation should be prescribed by ED physician based on CHA2DS2-VASc score
- Otherwise, admit for rate/rhythm control
No
- Rate control (goal HR <110 beats/min) (Class IIb)
- Diltiazem 5 mg IV q5 min until HR <120 beats/min, conversion, or 45 mg max dose (Class I)
- Consider infusion or PO following bolus (Class I)
OR
- Beta-1 selective beta blocker (Class I)
- Consider adjunct treatment
- Amiodarone (Class IIa)
- Magnesium (Class IIa)
- Digoxin (Class I)
- Avoid beta blocker with acute heart failure, acute COPD, acute asthma, or other contraindication (Class I)
IF rate <100 beats/min and normotensive without requiring additional IV medication:
- Discharge with 24-hr cardiology or ED follow-up
- Anticoagulation should be prescribed by ED physician based on CHA2DS2-VASc score
Otherwise, admit for rate/rhythm control
Medication Dosing