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nel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80:523–528. doi: 10.1016/j.resuscitation.2009.01.017 ATRIAL FIBRILLATION OR FLUTTER WITH RAPID VENTRICULAR RESPONSE: PART 1

ELECTRICAL THERAPIES Recommendations for Electrical Therapies for Atrial Fibrillation/Flutter COR LOE Recommendations

1 C-LD 1.  In adult patients with hemodynamic instability attributable to atrial fibrillation or atrial flutter with rapid ventricular rates, immediate electrical cardioversion should be performed to restore sinus rhythm.

1 C-LD 2.  Urgent direct-current cardioversion of new onset atrial fibrillation or atrial flutter with rapid ventricular rates in the setting of acute coronary syndrome is recommended for adult patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control.

2a B-R 3.  For synchronized cardioversion of atrial fibrillation in adults using any currently US-approved biphasic waveform defibrillator, an initial energy setting of at least 200 J is reasonable and incremented in the event of shock failure, depending on the biphasic defibrillator used.

2b B-R 4.  The usefulness of double synchronized cardioversion of atrial fibrillation in adults as an initial treatment strategy is uncertain.

2b C-LD 5.  For synchronized cardioversion of atrial flutter in adults, an initial energy setting of 200 J may be reasonable and incremented in the event of shock failure, depending on the biphasic defibrillator used.

2b C-LD 6.  The usefulness of double synchronized cardioversion as a rescue treatment for shock-refractory atrial fibrillation in adults is uncertain.

Synopsis Atrial fibrillation (AF) is a disorganized atrial rhythm due to multiple reentry (self-circulating) circuits throughout atrial myocardium. Atrial flutter is a more organized tachyarrhythmia caused by a single macroreentrant atrial circuit. The two arrhythmias are common, often co-exist, and are treated similarly. Treating AF/flutter with rapid ventricular rates depends on hemodynamic stability. Unstable patients and those with rate-related ischemia often need urgent electrical cardioversion (Figure 7). Stable patients can be treated pharmacologically to achieve rate or rhythm control. Conversion of AF/flutter greater than 48 hours in nonanticoagulated patients risks thromboembolic events. For acute AF/flutter assessed as less than 48 hours, decisionmaking is more nuanced, requiring expert consultation unless emergent cardioversion is needed. Pre-excited AF/flutter (Wolff-Parkinson-White) is covered under Wide-Complex Tachycardias.1 Electrical cardioversion is influenced by many factors. Technical features (beyond energy setting) affecting shock success include pad dimensions, pad location, minimizing impedance barriers, shock waveform, and timing (proper electrocardiogram

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