From the Guidelines
Prehospital treatment for atrial flutter should prioritize stabilizing the patient and controlling the ventricular rate, with a focus on hemodynamically stable patients using rate control medications such as diltiazem or metoprolol, as recommended by the 2015 ACC/AHA/HRS guideline 1.
Key Considerations
- For hemodynamically stable patients, monitor vital signs closely and provide supplemental oxygen if needed.
- Establish IV access and consider rate control medications such as:
Unstable Patients
- For unstable patients presenting with hypotension, altered mental status, chest pain, or heart failure, synchronized cardioversion is indicated starting at 50-100 joules, increasing as needed if initial attempts fail 1.
- Prior to cardioversion, consider sedation with midazolam 2-5 mg IV if time permits.
- Amiodarone (150 mg IV over 10 minutes, followed by infusion of 1 mg/min for 6 hours) may be used in some protocols for patients with rapid ventricular rates who don't respond to initial interventions.
Ongoing Care
- Continuous cardiac monitoring is essential throughout transport, as is documentation of rhythm strips before and after interventions.
- The goal of prehospital management is to control ventricular rate, improve hemodynamic stability, and safely transport the patient for further evaluation and definitive treatment.
Guideline Recommendations
- The 2015 ACC/AHA/HRS guideline recommends oral dofetilide or intravenous ibutilide for acute pharmacological cardioversion in patients with atrial flutter 1.
- Elective synchronized cardioversion is indicated in stable patients with well-tolerated atrial flutter when a rhythm-control strategy is pursued 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Atrial Flutter Prehospital Treatment
- Atrial flutter is a macroreentrant arrhythmia that is associated with cardiovascular and pulmonary disease 2.
- The most common form of atrial flutter involves a large reentrant circuit within the right atrium, encircling the tricuspid annulus 2.
- Treatment of atrial flutter often involves electrical cardioversion and/or antiarrhythmic medications, but antiarrhythmic drugs alone control atrial flutter in only 50% to 60% of patients 2.
- Prehospital management of rapid atrial fibrillation, which is related to atrial flutter, can be treated with symptomatic/supportive care, and cautious observation, as it is an infrequently encountered, predominantly hemodynamically stable cardiac arrhythmia 3.
- Atrioventricular node blocking agents, including beta-adrenergic blockers, non-dihydropyridine calcium channel blockers, and digoxin, are usually effective in controlling ventricular rate in atrial fibrillation and flutter 4.
- Catheter ablation has been established in randomized trials to be superior to medical management in terms of safety, efficacy, and clinical outcomes, including hospitalization and quality of life, for typical atrial flutter 5.
Prehospital Treatment Options
- Symptomatic/supportive care, including observation, and interventions with nitroglycerine, furosemide, aspirin, morphine, and/or IV fluid bolus therapy 3.
- Atrioventricular node blocking agents, including beta-adrenergic blockers, non-dihydropyridine calcium channel blockers, and digoxin 4.
- Electrical cardioversion may be considered in certain cases, but its use in prehospital settings is not well established for atrial flutter 2, 4.
Considerations for Prehospital Treatment
- The clinical situation and patient characteristics, such as myocardial ischemia, myocardial infarction, hyperthyroidism, and bronchial asthma, should be taken into account when selecting a treatment option 4.
- The presence of atrial fibrillation with Wolff-Parkinson-White syndrome requires special consideration, as certain medications can worsen the condition 4.