HWN Suggests

Is This Sinus?

If you ever have difficulty distinguishing the buried P-waves of atrial flutter, you can block down the AV node with vagal maneuvers or Adenosine and the slowing of the ventricular rate will unmask the underlying atrial rhythm. Narrow-complex tachycardia at a rate of 130-170: suspect flutter!!

If the patient is stable, the first priority is to achieve ventricular rate control with beta-blockers or nondihydropyridine calcium channel blockers. This patient was given a Diltiazem bolus and then placed on a drip which improved his rate into the 80s, although he was still in 2:1 atrial flutter.

Long-term management options for stable patients can be divided into rate control…

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  The Lewis Lead

The Lewis lead configuration (S5-lead placement) is used to better detect atrial activity in relation to that of the ventricles.

 Atrial Fibrillation/Flutter Best Practice Checklist

Acute, symptomatic atrial fibrillation / flutter is a complex condition that may be caused by an isolated electrophysiological disorder (primary arrhythmia) or is a symptom of an underlying disease process (secondary arrhythmia, note that this is less common).

 EM@3AM: Atrial Flutter

CCB and beta-blockers for rate control in the stable patient. Synchronized cardioversion (25-50J) in the unstable patient. Adenosine can slow down rate long enough to expose flutter waves.

Articles of Interest

Case Report: SVT, A-fib, or A-flutter?

The machine interpretation registered this as a wide QRS, however upon careful inspection of all leads, the QRS is narrow. Our differential included SVT and atrial flutter; we believed sinus tachycardia (initial rate too fast) and atrial fibrillation (regular R-R interval) were less likely.

Atrial Flutter Basics

The rate isn’t always exactly 150. If the rate is slower (e.g. HR 125-140, it can resemble Sinus Tachycardia. Therefore, in any regular narrow-complex tachycardia with HR 130-170, it is important to consider atrial flutter. Also Atrial flutter patients are often stable, and therefore, there is time to work up the EKG

EMS Protocol of the Week - Atrial Fibrillation/Atrial Flutter (Adult)

If stable, crews will progress to OLMC contact to request either diltiazem (0.25mg/kg IV bolus) or amiodarone (fixed dose of 150mg infusion over 10 minutes). If the crew is requesting diltiazem, be sure to check the math for the appropriate weight-based dosing. Also note that the Key Points section recommends halving the dose for certain patient subsets.

Episode 15 – Atrial Fibrillation/Flutter

The atrial rate in atrial flutter is usually around 300 per minute and usually 2:1, 3:1 or 4;1 block results in a more rapid ventricular rate than seen here.

Metoprolol vs. Diltiazem for Rate Control of A-fib/flutter with RVR

Overall, these data demonstrate a more rapid reduction in heart rate with diltiazem when compared with metoprolol in AF with RVR. While this does not seem to translate into decreased ED length of stay or admission rate,...