Therapy

• Try carotid sinus massage or ask the patient to perform a Valsalva manoeuvre ^d
• Give adenosine ^a  3mg, 6mg, 9mg, 12 mg ^a, unless the patient is on dipyridamole. ^a  
  • If a central line is in-situ, use it ^a  

Acute-onset atrial flutter

Alternatives include:

• calcium-channel blockers: verapamil ^a or diltiazem ^a  
• beta-blockers: esmolol ^a   or sotalol ^a    
  

Cardioversion is more likely to be successful if ^a  

• the onset of this episode of arrhythmia is recent
• your patient is young  

Anticoagulate the patient before and after cardioversion ^c  

Consider giving an infusion of ibutilide before cardioversion ^a  

There is no clear benefit from

• transoesophageal echocardiography ^b  
• using propafenone before DC cardioversion ^d  
• different pad or electrode positions ^d  

Alternatives include:

• pharmacological cardioversion
  
  • flecainide ^a  
  • ibutilide ^a  
  • amiodarone ^a  

Supraventricular tachycardia

Give adenosine ^a  3mg, 6mg, 9mg, 12 mg ^a, unless the patient is on dipyridamole. ^a  

• If a central line is in-situ, use it ^a  

• DC cardioversion ^a. Anticoagulate the patient before and after cardioversion ^c  
• calcium-channel blockers: diltiazem at least 0.15 mg/kg ^a  
• beta-blockers: e.g. esmolol ^c, nadolol ^a  
• sotalol 1.5 mg per kg over 10 minutes ^b  
• propafenone ^b  

Wolff-Parkinson-White syndrome

Terminate the rhythm using

• adenosine ^d
• amiodarone ^d
• flecainide ^d
• procainamide ^d
• esmolol ^d
• diltiazem 0.25 mg/kg ^a  

Ventricular tachycardias

Give iv amiodarone (initial rapid infusion - 150 mg over 10 mins; loading infusion - 1 mg/min for 6 hours; maintenance infusion - 0.52 mg/min for the remainder of 48 hours) ^a  

Alternatives include

• sotalol (100 mg iv over 5 minutes) ^a  
• procainamide (a bolus of 10 mg per kg at a rate of 100 mg per minute)  ^a  

N.B. Do not use class Ic anti-arrhythmics to treat patients with a recent myocardial infarction and frequent premature ventricular contractions (PVCs). ^a