Atrial fibrillation is one of the most common arrhythmias we encounter. However, there is no universally accepted approach for ED management of recent onset atrial fibrillation. There is a protocol called the “Ottawa Aggressive Protocol” for rapid discharge of ED patients with rapid onset atrial flutter or atrial fibrillation. (http://emed.wustl.edu/Portals/2/Answer%20Key%20PDF/2012/April2012/SecondYear.pdf)
In short the protocol states it is safe to cardiovert patients with recent onset A-fib or a-flutter (<48 hours) with either a 1 gram infusion of procainamide over an hour, and / or synchronized cardioversion. In the initial study, the protocol was an infusion of procainamide. For the individuals that failed chemical conversion, a dose of 150-200 J of synchronized cardioversion under procedural sedation was utilized. The success rate of procainamide alone was 58.3%, and overall with subsequent cardioversion was 91.7%.
There was an adverse even reported in 7.6% of patients, with the most common event being hypotension. No strokes or deaths were reported.
Rob Orman, of the ERCast Podcast, has a nice post about the safety of cardioversion in the ED, along with an excerpt from his podcast, with the relevant material starting at about 1:45 in to the audio. Here is the link http://blog.ercast.org/2012/10/should-we-cardiovert-atrial-fibrillation-in-the-ed/
If you want more links advocating this policy:
Dr. David Vinson, from “Physician’s Weekly,” replicated similar results in a smaller study. http://www.physiciansweekly.com/recent-onset-atrial-fibrillation-management/
And here is something from ACEP, although it is a bit older, from 2009: http://www.acep.org/Clinical—Practice-Management/Aggressive-Ottawa-Protocol-for-A-Fib-Succeeded-in-ED/
What do you all think? Have you utilized this approach before? What is your approach to the recent onset atrial fibrillation patient? Please discuss.