Journal Logo

Clinical Pearl

Clinical Pearl

The Crashing AFib Patient in the ED

doi: 10.1097/01.EEM.0000513587.42037.7d


    The current approach to the atrial fibrillation patient with a rapid ventricular response who is very hypotensive, of course, is to cardiovert, but this rarely works, especially if the patient is chronically in AF. Instead these techniques may give a better outcome.

    • Use maximum energy on the first attempt — this will not cause more cardiac injury than the use of fewer joules — and position the pads optimally. Use AP pad placement (R parasternal and L tip of scapula), which has been shown in some studies to have a higher success rate than typical anterolateral placement.
    • The coronary arteries fill during diastole. Raising the diastolic blood pressure >60 mm Hg improves blood flow to the coronary arteries and makes the myocardium less irritable. Use push-dose phenylephrine, 50-200 mcg q 1-2 min PRN, to raise the diastolic blood pressure >60 mm Hg. This will temporize the situation and make the patient's heart more likely to slow down. Phenylephrine is not a chronotrope and adds some vagal tone, which may help with the heart rate.
    • Magnesium? No. Recent literature indicates that it is of no benefit.
    • Work on rate control now that the blood pressure is a bit higher. Use amiodarone 150 mg slowly to reduce the risk of hypotension. Alternatives are diltiazem and beta-blockers (esmolol). Again, go low and slow: 2.5 mg/min aliquots of diltiazem, for example.
    • Now return to the underlying problem of AF. Increase your chances of synchronized cardioversion with pharmacological enhancement. Several agents can be used, but ibutilide has the most supportive data. Pretreating a patient with ibutilide (0.01 mg/kg over 10 minutes, waiting 10 minutes, and then cardioverting) significantly increases the chance of successful cardioversion and the duration of time the patient remains in sinus after cardioversion. (Sources: Heart 1999;82[6]:726; Circ Arrhythm Electrophysiol 2016;9[9], doi: 10.1161/CIRCEP.116.004521; Circulation 2014;130[23]:2071; J Cardiovasc Med 2006;7[2]:124.)

    This Clinical Pearl first appeared on Subscribers receive a new pearl by email every Wednesday. Visitwww.EMedHome.comfor more information. on

    Visit our website for videos and podcasts from Amal Mattu, MD, and other noted emergency physicians from at and EMedHome's video lectures at

    This Month's Podcast

    Amal Mattu, MD: The latest literature on transient ischemic attack, cellulitis, and RBC transfusions in the ED; Dr. Mattu is one of the premier speakers in emergency medicine and a professor of emergency medicine and the vice chair of emergency medicine at the University of Maryland School of Medicine in Baltimore.

    This Month's Video

    Nilesh Patel, DO: Acute Intermittent Porphyria: An Emergency Medicine Challenge: Dr. Patel is an assistant professor of clinical emergency medicine at New York Medical College and the emergency medicine residency program director at St. Joseph's Regional Medical Center in Paterson, NJ.

    Wolters Kluwer Health, Inc. All rights reserved.