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Initial stabilization
Initial priorities
Airway protection triggers
Depressed consciousness with hypoventilation
Refractory hypoxemia
Breathing support
Oxygen for SpO2 below local target
Noninvasive ventilation for acute pulmonary edema
Circulation actions
If hypotension with altered mentation, immediate synchronized cardioversion
If shock or ischemic chest pain, immediate synchronized cardioversion
If acute pulmonary edema, immediate synchronized cardioversion
Monitoring
Continuous ECG
NIBP every 3 to 5 minutes or arterial line if unstable
Pulse oximetry
Rhythm identification
Atrial fibrillation features
Irregularly irregular R R intervals
No discrete P waves
Atrial flutter features
Regular narrow complex tachycardia with ventricular rate often near 150
Sawtooth flutter waves in inferior leads
Wide complex tachycardia safety assumptions
If wide and irregular, treat as atrial fibrillation with pre-excitation until proven otherwise
If wide and regular, consider ventricular tachycardia until proven otherwise
Hemodynamic instability definition
Instability criteria
Systolic BP below 90 mmHg with hypoperfusion
Ongoing ischemic chest pain
Acute heart failure with pulmonary edema
Altered mental status attributed to arrhythmia
Immediate consult triggers
Cardiology or electrophysiology
Suspected pre-excitation
Refractory rapid ventricular response
Need for urgent rhythm control with complex comorbidity
Critical care
Persistent instability after initial intervention
Need for vasoactive infusion
Key decision points
Management pathway selection
Unstable atrial fibrillation or flutter
Synchronized cardioversion pathway
Peri-procedural anticoagulation consideration
Stable with rapid ventricular response
Rate control pathway
Rhythm control option selection based on onset and stroke risk
Stable without rapid ventricular response
Anticoagulation and outpatient rhythm strategy
Onset timing framework
Onset under 48 hours
Rhythm control option with peri-procedural anticoagulation based on stroke risk
Onset over 48 hours or unknown
Anticoagulation 3 weeks before elective cardioversion
TEE guided cardioversion with immediate anticoagulation alternative
Anticoagulation minimum 4 weeks after cardioversion
Reversible trigger screen
Trigger categories
Sepsis or systemic infection
Hypovolemia or hemorrhage
Hypoxia or COPD exacerbation
Pulmonary embolism
Thyrotoxicosis
Alcohol or stimulant exposure
Postoperative state
Acute coronary syndrome
Decompensated heart failure
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.