A-Fib Unleashed!

Curbside consult with electrophysiologist Randy Jones MD about the fine points of atrial fibrillation managment.

Atrial fibrillation management…including

  • Proper pad placement.
  • The difference between a-fib and a-flutter.
  • How much energy to use.
  • What to do when that nice sinus rhythm after cardioversion turns back into a-fib.
  • What’s the deal with mixing calcium channel and beta blockers?
  • The best agents for acute rate control.
  • Do we need to worry about ventricular dysrhythmias after cardioversion?
  • IV Procainamide for emergency department cardioversion of a-fib


  1. Lomberg

    Hey Rob,

    this podcast You asked for feedback, and now you´ll get some. I am a German medical 5th yera actually working in something like an ED, even though EM in Germany ist so for not a speciality for its own, unfortunately. By chance I found the stuff You and the guys of LITFL, EMRAP and the rest do, and I am very impressed how You use the Web 2.0 media. I definitely think that this way of peer review, the close connections of You guys to each other will improve knowledge in EM by far more than only using the tradiitional approach like writing papers an that stuff. Thanx for doing that for free. I tried to start a podcast with EM-related themes in German, unfortunaly the response is poor, partly probably because currently there is a difficult way to go for EM to become a speciality here, because of huge resistence of the big bosses in IM, Surgery and Anaesthesiology, hope that´ll end up soon.
    Please go on guys, You´re doing a great job.


  2. Joe Howton

    Very helpful podcast, Rob. Thanks!
    You mention that you have to wait 6 hours for an empty stomach prior to procedural sedation. I could be wrong, but my impression has been that has been shown to be unnecessary. Perhaps this would be a useful topic for discussion/debate.

    Any chance you will do a podcast on end tidal CO2? Both for procedural sedation, and for it’s many other uses? I’ve tried to use it in my ED for codes, sedation, etc and am stymied by the RN staff every time. We have the equipment, but none of the staff seem to be familiar with how to use it. I believe it’s an invaluable adjunct that we are missing out on.

    Joe H.
    Portland, Oregon

  3. Pingback: The LITFL Review 011 - Life in the Fast Lane Medical Blog

  4. Pingback: Best Of The LITFL Review 2011 - Life in the Fast Lane Medical Blog


    thanks. in fact in my area in ER.. our cardiologist really are scared of Electrical cardioversion of AF and they prefer to admit all AF patient for amiodarone infusion.. i gave them punch of articles on safety of elect. cardioversion in er.. but still they refuse to do it . part of it due to unfamiliarity with procedural sedation in er..

    is there any difference in risk of stroke between pharmacological & electrical cardioversion of acute af in er?

    1. Rob Orman


      The risk of stroke with cardioversion of properly selected A fib patients is extremely small. The limited data available show no difference in stroke rate between pharmacologic and electrical cardioversion. The stroke rate for both being essentially zero.

      1. Ken Grauer, MD

        @Rob -- I think the key words in your reply to Hassan are “properly selected”. How in the ED setting would you define a “properly selected” patient with AFib (who should therefore be at essentially zero risk of stroke from cardioversion)? I would imagine one key factor in determining lower risk would be very recent onset -- with onset of the arrhythmia not always being easy to determine.

  6. Ken Grauer, MD

    Truly excellent 2-part ERCast podcast. EP cardiologists are the true “arrhythmologists” -- so THANK YOU!

    I have 3 comments on this AFib 2-parter with Randy Jones:
    1) In my experience -- the need for emergent cardioversion of AFib is rare. The one exception to this might be with very rapid AFib in a patient with WPW (when ventricular rates may attain 250/minute or more). Emergent cardioversion is not benign -- including potential risk for stroke (especially if anticoagulation status is uncertain as it often is). Given that approximately 50% of patients who present with a new AFib episode will be in sinus rhythm within ~24 hours without any specific treatment beyond rate control (with even more spontaneously converting if you fix the precipitating factor -- ie, heart failure) -- I would think the true need for the ED physician to emergently cardiovert AFib (assuming no WPW) would be rare. Listening to your podcast gave me the opposite impression …

    2) I was not aware of increased current use of IV procainamide loading for acute conversion of new-onset rapid AFib or AFlutter as was mentioned. Reminds me of the days of Quinidine (similar effect in many ways to procainamide as a IA agent). It didn’t sound like routine use of an AV nodal blocking agent was advocated in your podcast. Because of the real risk (esp. with flutter) of slowing the flutter rate (say from 300-to-200/minute) with unopposed IA effect potentially then leading to 1-to-1 AV conduction (allowing increase of the ventricular rate to ~200/minute) -- shouldn’t an AV nodal blocking agent be routinely given if IV procainamide loading is used for acute AFib-Flutter conversion?

    3) As to your comments about combined AV nodal blocking effect using beta-blockers and diltiazem -- my impression had always been that the “no-no” to avoid was giving IV beta-blocker very soon after IV calcium blocker (or vice versa) -- but that IF the patient was already on a PO beta-blocker -- that IV diltiazem was then perfectly safe to use.

    THANKS again for a truly excellent 2-part podcast on AFib!


      nice review.. although i’m interested in electrical cardioversion of acute AF for those who are low risk, young patients.. i didn’t hear any comment about this practice although it’s much safer than pharmacological cardioversion.

      1. Rob Orman


        We mainly use electrical cardioversion for recent onset a fib, both in young and old. I offer Procainamide in certain situations such as -- the patient has just eaten, there is anxiety about getting shocked and the patient would prefer meds first…


          in fact excellent review and practical… lets suppose I receive a patient who is 60 year old male known AF, EF 30% on warfarin. comes with rapid AF (140/m) . if he is in Heart Failure , am I going to Electrically cardiovert him? since he is already on punch of AVN blockers including digoxin, carvidolol !! keeping in mind that rapid heart rate could be due to underlying stress like heart failure for example. If the shock failed to convert the rythm, will it control the rate? in this case the choice of Rx is very limited. and I’m not aware of the risk of stroke for those who are already on warfarin even if there is thrombus in left atriam ?

      2. Ken Grauer, MD

        @ Hassan -- Maybe I’m “old school” -- but I simply don’t understand the need (or desire) for immediate ED cardioversion of the patient you describe Hassan UNLESS this patient is hemodynamically unstable. At least in my experience -- though the patient may clearly be symptomatic from their acute exacerbation of heart failure (which was aggravated by onset of rapid AFib) -- well over 90% of these patients (if not 99%) are not hemodynamically unstable at the time they present to the ED.

        Given: i) Primum non nocere; ii) the reality that at least 50% of all patients you see in the ED with onset of AFib will be in sinus rhythm within 24 hours even if you do nothing (and more than this will spontaneously convert if you fix the precipitating cause) -- what is there to benefit from a procedure that isn’t totally benign (ED cardioversion) when another approach may be comparably effective with less risk? ; iii) Treatment of the underlying cause (ie, diuresis perhaps of this patient with heart failure) should improve his underlying condition; iv) the edge off this patients new rapid AFib can usually be better controlled with cautious appropriate use of AV nodal blockers (ie, IV Dilt per drip) even if other AV nodal blockers (Dig, beta-blockers) are already on board -- which together with treating the underlying cause should usually reduce the rapid ventricular response to AFib; and v) perhaps a better decision re the pros and cons of cardioversion of this patient might be reached after control of his acute exacerbating condition and after a better chance of evaluation (ie, determining if there is thrombus sitting in the left atrial appendage).

        As to your question -- IF electrical cardioversion fails to convert this patient out of AFib -- then it will do nothing for the rapid ventricular response (which as you allude to, is due to other factors -- namely acute exacerbation of his probable precipitating condition = heart failure).

        The above just random thoughts from “the old school” … Thanks for listening. This 2-parter on AFib by Rob with Randy Jones was truly excellent!

  7. Pingback: EM Broad Spectrum: The Ultimate Shock-Block: How to Take Back “Charge” in Your ED

  8. Pingback: Management of unstable atrial fibrillation in the emergency department | First10EM

Awesome article, I know - please share your erudite thoughts...