Action
Perform immediate direct current cardioversion with sedation:
- 200 J biphasic (Class I)
- 200-360 J monophasic (Class I)
Decision
Was cardioversion successful?
Success includes
- Conversion to normal sinus rhythm
- Heart rate <120 beats/min
- Mean arterial pressure >65 mm Hg
Yes
- Further stabilize
- Admit (Class I)
No
Repeat direct current cardioversion with sedation (Class I):
- Increase energy level
- Anterior-posterior pad placement (Class indeterminate)
If unsuccessful:
- Ibutilide 1 mg IV over 10 min followed by sedation and cardioversion (Class IIa)
- Dosing for weight ≥60 kg
- Rate control with diltiazem IV bolus and infusion (Class I)
- Procainamide IV (Class IIa)
- Amiodarone IV (Class IIa)
- Magnesium IV (Class IIa)
- Perform further cardioversion attempts (Class I)
- Administer vasopressor support as needed (Class
Plus:
indeterminate)
