Synchronized cardioversion<unk>  - start at 50 J<unk>  fibrillation - start at 200 J
Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, altered mental status
If shock does not work:<unk>  - start at 50 J<unk>  fibrillation - start at 200 J
Push-dose phenylephrine
Will maintain BP when give rate-control medications
50-200mcg q2-5min with goal DBP >60
Will maintain BP when give rate-control medications
50-200mcg q2-5min with goal DBP >60
If mild or no symptoms and pulse only mildly elevated (<110bpm) ok to manage with PO meds
Less reactive to PO medication than<unk>  fibrillation
Cardioversion is preferred and treats 96-97% of<unk> 
Goal <110bpm
Make sure you are not slowing down a normal physiologic response (e.g. fever, hypoxia, etc)
RACE-II<unk>  demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome
Make sure you are not slowing down a normal physiologic response (e.g. fever, hypoxia, etc)
RACE-II<unk>  demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome
Consider for:
Symptoms <48hr
New diagnosis
No history of similar episodes
No LV dysfunction
No mitral valve disease
No prior thromboembolic event
Already Anticoagulated
If cardioversion is considered, pretreatment with rate or rhythm control medications can reduce effectiveness
90% effective, 60% effective with pretreatment
Symptoms <48hr
New diagnosis
No history of similar episodes
No LV dysfunction
No mitral valve disease
No prior thromboembolic event
Already Anticoagulated
90% effective, 60% effective with pretreatment
Anticoagulation with Heparin or LMWH should be considered before cardioversion if time permits, otherwise immediately<unk> ter cardioversion. (unless you are sure it has been <48 hours since onset of<unk> ib)  
Generally cardioversion while anti-coagulated is believed to be safe with a 1.3% risk of thromboembolism if on aspirin or other anticoagulant  However the risk may be as great as 2% risk<unk> ter 48 hours and preference should be given to anticoagulation prior to cardioversion in longer cases
Avoid AV nodal agents
Unstable:
Unsynchronized cardioversion (200J)
Procainamide (if cardioversion unsuccessful)
20-50mg/min until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of original width, or total of 17mg/kg is given; followed by continuous infusion of 1-4mg/min
Stable:
Try to avoid cardioversion without adequate anticoagulation
Unsynchronized cardioversion (200J)
Procainamide (if cardioversion unsuccessful)
20-50mg/min until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of original width, or total of 17mg/kg is given; followed by continuous infusion of 1-4mg/min
20-50mg/min until arrhythmia is controlled, hypotension occurs, QRS complex widens by 50% of original width, or total of 17mg/kg is given; followed by continuous infusion of 1-4mg/min
Try to avoid cardioversion without adequate anticoagulation
Atrial flutter
Can be difficult to distinguish from atrial fibrillation
Wide-complex tachycardia
Regular
Narrow-complex tachycardia
AV Node Independent
Atrial fibrillation 
Sinus tachycardia