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Atrial fibrillation

  • Admission orders

    • Admit: Telemetry
    • Diagnosis: Atrial Fibrillation
    • Condition: Guarded
    • Vital Signs: q 2 h x 4; then q 4 h, continuous tele
    • Allergies:
    • Nursing: O2 2L per NC if sat < 93
    • Diet: Heart Healthy Diet
    • Activity: As Tolerated
    • Labs:
      • CBC, chem
      • enzymes: CK-MB, troponin
      • TSH
      • iron panel
      • ECG, chest x-ray (CXR), echo
    • IV: Heplock IV
    • Special:
    • Medications:
      • Metoprolol 5 mg IV over 2-3 minutes; if HR > 100 bpm and SBP > 100 mmHg, repeat every 5 minutes x 2, to a maximum of 15 mg
      • Metoprolol 50 mg PO every 12 hours - begin in 6 hours
      • Warfarin 5 mg PO tonight; dose of warfarin to be adjusted daily based on INR
  • Discharge

    • anticoagulation clinic
  • CHADS2 score

    • 1 point each: CHF, HTN, Age > 75, DM
    • 2 points if PMH stroke, TIA, PE or DVT
  • ED Tx

    • if unstable, give cardioversion 50-100J
    • rate control:
      • diltiazem 20 mg IV over 2 min followed by 5-15 mg/h. If no response after 15 min, give second dose 25 mg.
      • if EF < 40%, use amiodarone 5 mg/kg IV over 30 min followed by 1200 mg over 24 hr.
    • anticoagulate if > 48 hrs: heparin 80 U/kg IV followed by 18 U/kg/h IV
    • long term anticoagulation:
      • daily aspirin if CHADS2 = 0
      • warfarin if CHADS 2 > 1
      • pt preference if CHADS2 = 1
    • other:
      • r/o atrial thrombus with TEE before cardioversion

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