Synchronized cardioversion (100-200J)<unk><unk>  - start at 200 J<unk>  flutter - start at 50 J
If you have time sedate with etomidate or ketamine before defibrillation
Dose (Etomidate): Start with 0.1mg/kg IV; repeat if needed
Dose (Ketamine): Start with 0.5mg/kg IV; repeat if needed
Indications: ischemic chest pain, SBP < 90, acute pulmonary edema, altered mental status
Consider cardiostable sedation such as 5mg etomidate
+/- subdissociative pain dosage ketamine at 15mg
If shock does not work:
Verify not preexcitation (WPW)
Increase diastolic BP to perfuse the heart

Push-dose phenylephrine
Will maintain BP when give rate-control meds
50-200mcg q2-5min with goal MAP 70-75
Can also do phenylephrine as a drip or norepinephrine drip
After MAP is better then try to rate control with one of the following
Amiodarone 150mg over 10min (preferably through central venous access) for up to 6 doses OR
esmolol drip (easy to turn off) OR
diltiazem infusion 2.5mg/min until HR <100 or max 50mg
Magnesium
Be careful since can worsen vasodilation for these hypotensive patients
2 g over 1-5 min, repeat if no response after 15 min, then consider 1-2 g/h for 4 hrs if response
Significantly less effective than amiodarone or calcium-channel blockers
Ensure baseline magnesium level
Check magnesium q2hrs if infusing<unk><unk>  - start at 200 J<unk>  flutter - start at 50 J
If you have time sedate with etomidate or ketamine before defibrillation
Dose (Etomidate): Start with 0.1mg/kg IV; repeat if needed
Dose (Ketamine): Start with 0.5mg/kg IV; repeat if needed
Dose (Etomidate): Start with 0.1mg/kg IV; repeat if needed
Dose (Ketamine): Start with 0.5mg/kg IV; repeat if needed
+/- subdissociative pain dosage ketamine at 15mg
Verify not preexcitation (WPW)
Increase diastolic BP to perfuse the heart

Push-dose phenylephrine
Will maintain BP when give rate-control meds
50-200mcg q2-5min with goal MAP 70-75
Can also do phenylephrine as a drip or norepinephrine drip
After MAP is better then try to rate control with one of the following
Amiodarone 150mg over 10min (preferably through central venous access) for up to 6 doses OR
esmolol drip (easy to turn off) OR
diltiazem infusion 2.5mg/min until HR <100 or max 50mg
Magnesium
Be careful since can worsen vasodilation for these hypotensive patients
2 g over 1-5 min, repeat if no response after 15 min, then consider 1-2 g/h for 4 hrs if response
Significantly less effective than amiodarone or calcium-channel blockers
Ensure baseline magnesium level
Check magnesium q2hrs if infusing
Push-dose phenylephrine
Will maintain BP when give rate-control meds
50-200mcg q2-5min with goal MAP 70-75
Can also do phenylephrine as a drip or norepinephrine drip
Will maintain BP when give rate-control meds
50-200mcg q2-5min with goal MAP 70-75
Amiodarone 150mg over 10min (preferably through central venous access) for up to 6 doses OR
esmolol drip (easy to turn off) OR
diltiazem infusion 2.5mg/min until HR <100 or max 50mg
Be careful since can worsen vasodilation for these hypotensive patients
2 g over 1-5 min, repeat if no response after 15 min, then consider 1-2 g/h for 4 hrs if response
Significantly less effective than amiodarone or calcium-channel blockers
Ensure baseline magnesium level
Check magnesium q2hrs if infusing
Make sure you are not slowing down a normal physiologic response (e.g. fever, hypoxia, shock, etc.)
Goal <110bpm
RACE-II<unk>  demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome
RACE-II<unk>  demonstrated that lenient control (goal HR < 110bpm) was noninferior to strict control (HR < 80 bpm) in preventing the primary outcome
If mild or no symptoms and pulse only mildly elevated (<110bpm) ok to manage with PO meds
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 after cardioversion. (unless you are sure it has been <48 hours since onset of afib)  
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 after 48 hours and preference should be given to anticoagulation prior to cardioversion in longer cases
Bolus 0.25mg/kg (average adult dose 20mg) over 2 min
If, after 15min 1st dose is tolerated but inadequate re-bolus 0.35mg/kg
If patient responds start infusion at 5-15mg/hr or give PO diltiazem 60mg QID
Preferred in patients with chronic lung such as Asthma and COPD
Decompensated heart failure
Preexcitation (especially in pediatrics)
Significant hypotension
Bolus 2.5-5mg IVP over 2min q5min up to 3 doses
If patient responds orally load with 25-50mg. The initial oral dose may be estimated based on the IV dose required, based on a 1:2.5 conversion from IV to PO
Particularly useful when A-fib associated with exercise, after acute MI, or with thyrotoxicosis
Long-term β-blocker improves patient survival (CCB may worsen outcomes), thus starting a β-blocker upon discharge, strongly consider using the agent for rate control also.
COPD
Asthma
Decompensated heart failure
Hypotension
Bolus 0.5mg/kg over one minute, followed by 50 µg/kg/min
If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min
If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min
If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes
Use if unsure whether patient will tolerate a β-blocker since the duration of action is only 10 minutes
0.25mg IV q2hr up to 1.5mg, then 0.125-0.25mg PO or IV QD
Adjust dose in presence of renal failure, amiodarone, etc
Consider as initial therapy for patients with LV dysfunction who:
Do not achieve rate control targets on β-blockers alone
Cannot tolerate addition of or increased doses of β-blocker due to decompensated CHF
Would have digoxin added anyway to improve CHF symptoms independent of A-fib
Consider as initial therapy in patients with severe hypotension
Consider as 2nd agent in patients in whom IV BB or IV CCB has failed to control their rate
May take up to 6-8 hours to work
Do not achieve rate control targets on β-blockers alone
Cannot tolerate addition of or increased doses of β-blocker due to decompensated CHF
Would have digoxin added anyway to improve CHF symptoms independent of A-fib
Load 3-7mg/kg IV over 30 min
then, 1200mg over 24hr via continuous infusion or in divided oral doses
Consider for patients with decompensated heart failure or those with accessory pathways
2nd-line agent for chronic rate control when beta-blockers and calcium-channel blockers, alone, combined, or when used with digoxin, are ineffective
4.5 IV over 30 min
IV MgSO4 appears to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control.
Given in conjunction with beta-blockers and calcium-channel blockers.
Avoid AV nodal agents
Unstable:
Synchronized cardioversion (120-200 joules for biphasic waveforms, 200 joules for monophasic waveforms)
Stable :
Procainamide (17 mg/kg loading dose at 20 to 50 mg/minutes or 100mg every 5 minutes, maintenance infusion 1 to 4 mg/minute) 
Ibutilide (1mg over 10 minutes, repeat 10 minute infusion can be given)
Avoid amiodarone, does not slow accessory pathway and has beta blocking properties, may increase conduction via accessory pathway
Cardioversion, consider sedation prior
Avoid AV nodal blocking agents (diltiazem, metoprolol) as can lead to ventricular<unk> /tachycardia
Try to avoid cardioversion without adequate anticoagulation
Synchronized cardioversion (120-200 joules for biphasic waveforms, 200 joules for monophasic waveforms)
Procainamide (17 mg/kg loading dose at 20 to 50 mg/minutes or 100mg every 5 minutes, maintenance infusion 1 to 4 mg/minute) 
Ibutilide (1mg over 10 minutes, repeat 10 minute infusion can be given)
Avoid amiodarone, does not slow accessory pathway and has beta blocking properties, may increase conduction via accessory pathway
Cardioversion, consider sedation prior
Avoid AV nodal blocking agents (diltiazem, metoprolol) as can lead to ventricular<unk> /tachycardia
Try to avoid cardioversion without adequate anticoagulation
Atrial fibrillation with RVR
Regular
Polymorphic ventricular tachycardia
AV Node Independent
Atrial flutter
Sinus tachycardia
Ventricular tachycardia
Atrial tachycardia 