Sinus tachycardia
Treat underlying cause
SVT
Vagal maneuvers (convert up to 25%)
Adenosine 6mg rapid IV push if patient hemodynamically stable (unstable should proceed directly to electrical cardioversion)
Can follow with repeat dose of 6 mg or 12mg if initially fails
If adenosine fails, initiate rate control with calcium channel blocker or beta blocker or use synchronized cardioversion
Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
Metoprolol 5mg IVP x 3 followed by 50mg PO
Synchronized cardioversion (50-100J)
Provide sedation prior to synchronized cardioversion if patient is hemodynamically stable
Atrial flutter
Stable: Consider rate control to HR < 110 bpm
Unstable: Synchronized cardioversion; start at 50J
Treat underlying cause
Vagal maneuvers (convert up to 25%)
Adenosine 6mg rapid IV push if patient hemodynamically stable (unstable should proceed directly to electrical cardioversion)
Can follow with repeat dose of 6 mg or 12mg if initially fails
If adenosine fails, initiate rate control with calcium channel blocker or beta blocker or use synchronized cardioversion
Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
Metoprolol 5mg IVP x 3 followed by 50mg PO
Synchronized cardioversion (50-100J)
Provide sedation prior to synchronized cardioversion if patient is hemodynamically stable
Can follow with repeat dose of 6 mg or 12mg if initially fails
If adenosine fails, initiate rate control with calcium channel blocker or beta blocker or use synchronized cardioversion
Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
Metoprolol 5mg IVP x 3 followed by 50mg PO
Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
Metoprolol 5mg IVP x 3 followed by 50mg PO
Provide sedation prior to synchronized cardioversion if patient is hemodynamically stable
Stable: Consider rate control to HR < 110 bpm
Unstable: Synchronized cardioversion; start at 50J
Multi-focal atrial tachycardia (MAT)
Treat underlying cause (hypokalemia, hypomagnesemia)
Consider diltiazem
Avoid beta blockers unless they are already known to be tolerated, as airway disease often co-morbid
If not symptomatic and rate < 110/120 bpm, may not require treatment (e.g., patient with MAT secondary to COPD)
Sinus Tachycardia with frequent PACs
Treat underlying cause
A fib / A Flutter with variable conduction (see also Atrial Fibrillation with RVR)
Check if patient has taken usual rate-control meds
If missed dose, may provide dose of home medication and observe for resolution
Determine whether patient is better candidate for rate control or rhythm control 
Rate control preferred with:
Persistent A fib
Less symptomatic patients
Age 65 or older
Hypertension
No heart failure
Previous failure to cardiovert
Patient preference
Rhythm control preferred with:
Paroxismal or new A fib
More symptomatic patients
Age < 65 years
Heart failure clearly exacerbated by A fib
No history of rhythm control failure
Patient preference
Rate control with:
Diltiazem
Metoprolol
Amiodarone (good in setting of hypotension, CHF)
Digoxin (good in setting of CHF)
Rhythm conversion with:
Synchronized Cardioversion (120-200 J)
Best performed on patients with new onset A fib or patients fully therapeutically anti-coagulated for > 3 weeks
Procainamide per Ottawa Aggressive ED Cardioversion Protocol
Treat underlying cause (hypokalemia, hypomagnesemia)
Consider diltiazem
Avoid beta blockers unless they are already known to be tolerated, as airway disease often co-morbid
If not symptomatic and rate < 110/120 bpm, may not require treatment (e.g., patient with MAT secondary to COPD)
Treat underlying cause
Check if patient has taken usual rate-control meds
If missed dose, may provide dose of home medication and observe for resolution
Determine whether patient is better candidate for rate control or rhythm control 
Rate control preferred with:
Persistent A fib
Less symptomatic patients
Age 65 or older
Hypertension
No heart failure
Previous failure to cardiovert
Patient preference
Rhythm control preferred with:
Paroxismal or new A fib
More symptomatic patients
Age < 65 years
Heart failure clearly exacerbated by A fib
No history of rhythm control failure
Patient preference
Rate control with:
Diltiazem
Metoprolol
Amiodarone (good in setting of hypotension, CHF)
Digoxin (good in setting of CHF)
Rhythm conversion with:
Synchronized Cardioversion (120-200 J)
Best performed on patients with new onset A fib or patients fully therapeutically anti-coagulated for > 3 weeks
Procainamide per Ottawa Aggressive ED Cardioversion Protocol
If missed dose, may provide dose of home medication and observe for resolution
Rate control preferred with:
Persistent A fib
Less symptomatic patients
Age 65 or older
Hypertension
No heart failure
Previous failure to cardiovert
Patient preference
Rhythm control preferred with:
Paroxismal or new A fib
More symptomatic patients
Age < 65 years
Heart failure clearly exacerbated by A fib
No history of rhythm control failure
Patient preference
Persistent A fib
Less symptomatic patients
Age 65 or older
Hypertension
No heart failure
Previous failure to cardiovert
Patient preference
Paroxismal or new A fib
More symptomatic patients
Age < 65 years
Heart failure clearly exacerbated by A fib
No history of rhythm control failure
Patient preference
Diltiazem
Metoprolol
Amiodarone (good in setting of hypotension, CHF)
Digoxin (good in setting of CHF)
Synchronized Cardioversion (120-200 J)
Best performed on patients with new onset A fib or patients fully therapeutically anti-coagulated for > 3 weeks
Procainamide per Ottawa Aggressive ED Cardioversion Protocol
Best performed on patients with new onset A fib or patients fully therapeutically anti-coagulated for > 3 weeks
ACLS: Tachycardia
Regular
PALS: Tachycardia
AV Node Independent
ACLS: Bradycardia
Sinus tachycardia
PALS: Bradycardia
Atrial tachycardia 