Atrial Fibrillation

View Rhythm Strip
Transcutaneous PacingStep-by-step setup, capture & troubleshooting
TC Pacing — Quick Steps
Full guide →
  1. Apply pads anterior–posterior; attach ECG leads from the pacer/monitor.
  2. Pre-medicate for discomfort: midazolam ± fentanyl if BP allows.
  3. Set mode Demand (synchronous), rate 60–80/min.
  4. Increase output (mA) by 5–10 until electrical capture (wide QRS after each spike).
  5. Confirm mechanical capture: palpate femoral/right brachial pulse (not carotid).
  6. Set final output ~10 mA above threshold; reassess BP, perfusion, mentation.
  7. Bridge to transvenous pacing or treat underlying cause.
ANTERIORANTPOSTERIORPOSTSandwich the heart between pads
A–P pad placement

Rhythm strip

Source ↗
No P wavesFibrillatory baselineIrregularly irregular R–RNarrow QRS
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Tap a label on the strip to highlight the matching feature below.

  • Absent P waves
  • Chaotic fibrillatory baseline
  • Irregularly irregular R–R intervals
  • Narrow QRS unless aberrancy
Recognition
  • Irregularly irregular R-R intervals
  • Absent P waves; chaotic fibrillatory baseline
  • Narrow QRS unless aberrant conduction
  • RVR commonly defined as ventricular rate > 110–120
Causes / triggers
  • PIRATES: Pulmonary (PE/COPD), Ischemia, Rheumatic/valvular, Anemia/Atrial enlargement, Thyroid, Ethanol/Electrolytes, Sepsis/Sleep apnea
Management
Unstable (any criterion below)
  • (SBP < 90 with hypoperfusion)
  • (cool, mottled, lactate ↑)
  • 120–200 J biphasic (consider sedation if time allows)
Stable rate control
  • 0.25 mg/kg IV over 2 min (≈ 20 mg) → may repeat 0.35 mg/kg in 15 min; infusion 5–15 mg/hr
  • 2.5–5 mg IV q5 min × 3 (avoid in decompensated HF / severe COPD)
  • 150 mg IV over 10 min then 1 mg/min — preferred in HF or hypotension-prone patients
  • 2 g IV — adjunct, especially if hypomagnesemic
Rhythm control / cardioversion
  • : 120–200 J biphasic synchronized
  • : ibutilide, procainamide, or amiodarone (institution dependent)
Anticoagulation (CHA₂DS₂-VASc)
Pearls / pitfalls
  • AFib with WPW (wide, irregular, very fast) → AVOID AV nodal blockers (diltiazem, beta-blockers, adenosine, digoxin). Use procainamide or cardiovert.
  • Rate control before rhythm control in most ED patients.

Educational reference only. Always follow current ACLS guidelines and institutional protocols.