When is prehospital care indicated for atrial flutter?

Updated: Nov 09, 2018
  • Author: Jesse Borke, MD, FACEP, FAAEM; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Prehospital treatment is usually only indicated in hemodynamically unstable patients. Refer to local protocols for emergency medical services (EMS) management.

Atrial flutter in an unstable patient should be treated immediately with synchronized cardioversion. Unstable patients are those with ongoing chest pain, severe shortness of breath, altered level of consciousness, or hypotension. The patient should be treated with an intravenous (IV) sedative prior to cardioversion if their condition permits.

In general, avoiding class I and III agents (eg, procainamide) in the prehospital setting is safest because of possible induction of a 1:1 conduction. Frequently, the rate can be slowed safely with administration of calcium channel blockers (class IV) or beta-adrenergic blockers (class II). Avoid giving procainamide or similar-acting medications prior to slowing the AV node conduction (eg, diltiazem), as slowing the atrial rate prior to the AV conduction rate can dangerously increase the ventricular rate by the induction of a lower conduction ratio (eg, inducing a 1:1 conduction as the atrial rate slows to 220 bpm in a patient who was initially exhibiting a 2:1 conduction at a rate of 300 A/150 V. As the atrial rate slows to 220 bpm, the ventricular rate increases to 220 bpm and the patient becomes less stable.).

For patient education information, see the Heart Health Center, as well as Atrial FlutterArrhythmias (Heart Rhythm Disorders)StrokeSupraventricular Tachycardia (SVT, PSVT), and Palpitations.

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