EMS Protocol of the Week - Atrial Fibrillation/Atrial Flutter (Adult)

This week starts off our three tachydysrhythmia protocols! First up – atrial fibrillation and atrial flutter. As in all dysrhythmia protocols, the first step for paramedics is to determine if the patient in front of them is stable or unstable. If unstable, electricity is indicated, and Standing Orders list instructions for synchronized cardioversion at stepwise increases in joule settings as necessary. If stable, crews will progress to OLMC contact to request either diltiazem (0.25mg/kg IV bolus) or amiodarone (fixed dose of 150mg infusion over 10 minutes). If the crew is requesting diltiazem, be sure to check the math for the appropriate weight-based dosing. Also note that the Key Points section recommends halving the dose for certain patient subsets. If the crew requests amiodarone, consider asking them why! The efficacy of amio is questionable, but some crews may prefer it if the patient’s blood pressures are soft, although I’d argue that if the patient is truly hypotensive, you may need to have a conversation with them discussing electrical cardioversion. Whichever medication is requested, don’t forget to think critically about the patient! Why are they sotachycardic? Are they clearly septic? Dehydrated? Maybe fluids – rather than forcing rate control – are in their best interest. Food for thought!

Reach out with any questions! Otherwise, I’ll see you next week for more fast heart stuff! Until then, www.nycremsco.org or the protocol binder for more.

Dave