ACLS rapid atrial fibrillation guideline



State of Wisconsin

Emergency Medical Services

Sample Medical Guidelines

|ACLS-Rapid Atrial Fibrillation |

|Priorities |Assessment Findings |

|Chief Complaint |Palpitations, fast heart rate, shortness of breath, chest pain, weakness |

|OPQRST |Onset and duration, precipitating factors and circumstances, associated symptoms, stroke |

| |symptoms, nausea, vomiting |

|Associated Symptoms/ Pertinent |Chest pain, shortness of breath, weakness, anxiety, leg swelling |

|Negative | |

|SAMPLE |Previous history, history of thyroid disease, CAD, cardiac medications |

|Initial Exam |Check ABCs and correct any immediate life threatening problems. |

|Detailed Focused Exam |Skin: Cool, pale diaphoretic |

| |Neck: JVD? |

| |Chest: Labored breathing |

| |Lungs: Wheezes, rales, rhonchi? Decreased breath sounds? |

| |Heart: Irregular, fast, murmur |

| |Legs: Edema? Signs of an acute arterial occlusion (embolism)? |

| |Neuro: ALOC? Signs of stroke? |

|Goals of Therapy |Decrease Rate, treat chest pain, treat CHF |

|Monitoring |BP, HR, RR, EKG, SpO2. |

|EMERGENCY MEDICAL RESPONDER (EMR) |

• Routine Medical Care

• Titrate oxygen therapy to the lowest level required to maintain an oxygen saturation greater than 93%

• If the patient is having difficulty breathing allow them to sit in position of comfort

|EMERGENCY MEDICAL TECHNICIAN (EMT) |

• If the patient experiences shortness of breath, follow the Congestive Heart Failure Guidelines

• If the patient has suffered a stroke, follow the Stroke Guidelines.

• ECG monitor or 12 lead acquisition, if approved.

|ADVANCED EMT (AEMT) |

• IV/IO NS @ TKO, if approved.

• If SPB < 100 mmHg give 500cc fluid bolus, and then reassess

o Consider Trendelenberg position, if there is no dyspnea

|Contact Medical Control for the following: |

|Additional fluid orders |

|INTERMEDIATE |

• Obtain a 12-Lead EKG if not already performed

• If the patient does not have a history of atrial fibrillation, consider the potential causes that may have a bearing on prehospital care, including:

o Acute coronary syndromes (e.g. AMI)

o Pulmonary embolism

o Alcohol use

o Stimulant drug abuse (e.g. cocaine and amphetamines)

• If the patient has a history of atrial fibrillation, consider possible causes of tachycardia, including pain, dehydration, hypotension, shock, hypoglycemia, hypoxemia, anxiety, fever, sepsis, drug induced, recent heavy exertion, hyperthyroidism and anemia.

• If the patient is hemodynamically and clinically stable, observe and monitor.

|Contact Medical Control for the following: |

|If the patient is unstable, consider cardioversion under direction of Medical Control. |

|PARAMEDIC |

• If the patient is hemodynamically and clinically stable, transport, observe and monitor. Efforts to reduce the heart rate will add little benefit in the absence of adverse effects from RAF.

• If the patient is hemodynamically or clinically unstable

o Prepare to perform synchronized cardioversion, consider pain management or sedation

o Perform first synchronized cardioversion @ 120-200 J biphasic (200 J monophasic)

o If synchronization is unsuccessful, turn sync off and attempt cardioversion

|Contact Medical Control for the following: |

|Additional orders to potentially include Cardizem. |

FOOTNOTES:

Criteria for characterizing a patient as “unstable”

• Hemodynamic Criteria

o SBP < 80 mmHg AND Heart Rate > 150 beats/min

• Clinical Criteria

o Signs of shock (poor perfusion) are present, including

▪ ALOC

▪ Absent radial pulses

▪ Pallor and diaphoresis

o Signs of pulmonary edema are present, including

▪ Labored breathing

▪ Rales (wet lungs)

▪ Hypoxia (SpO2 ................
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