Sandbox

Medication	Dose	Comments	Contraindications
Calcium-Channel Blockers
Diltiazem	Bolus 0.25 mg/kg (average adult dose 20mg) over 2 min If, after 15min 1st dose is tolerated but inadequate re-bolus 0.35 mg/kg If patient responds start infusion at 5-15mg/hr or give PO dilt 30mg QID	Preferred in patients with chronic lung such as Asthma and COPD	Decompensated heart failure Preexcitation (especially in pediatrics) Significant hypotension
Beta-Blockers
Metoprolol	Bolus 2.5-5mg IVP over 2min q5min up to 3 doses If patient responds orally load with 25-50mg	Particularly useful when A-fib a/w exercise, after acute MI, or w/ thyrotoxicosis Also long-term beta blocker improves patient survival whereas non-dihydropyridine calcium channel blockers may even worsen outcomes. Important to consider if a patient will most likely be started on a beta blocker upon discharge then strongly consider using the agent for acute conversion if they do not have any relative contraindications.	COPD Asthma Decompensated heart failure Hypotension
Esmolol	*Bolus 0.5 mg/kg over one minute, followed by 50 µg/kg/min *If, after 4min response is inadequate, re-bolus followed by infusion of 100 µg/kg/min *If, after 4min response is still inadequate, try final bolus followed by infusion of 150 µg/kg/min *If necessary, infusion can be increased to maximum of 200 µg/kg/min after another four minutes	*Use if unsure whether patient will tolerate a beta blocker since the duration of action is only 10 minutes
Other
Digoxin
	*0.25 mg IV q2hr up to 1.5 mg, then 0.125-0.25 mg PO or IV QD *Adjust dose in presence of renal failure, amiodarone, etc	*Consider as initial therapy for pts with LV dysfunction who: **Do not achieve rate control targets on beta blockers alone **Cannot tolerate addition of or increased doses of beta blocker due to decompensated CHF **Would have digoxin added anyway to improve CHF symptoms independent of A-fib *Consider as initial therapy in pts with severe hypotension *Consider as 2nd agent in pts in whom IV BB or IV CCB has failed to control their rate *May take up to 6-8 hours to work
Amiodarone	*Load 3-7 mg/kg IV over 30 min; then 1200 mg over 24hr via continuous infusion or in divided oral dosesKhan IA et al. Amiodarone for pharmacological cardioversion of recent-onset atrial fibrillation. Int J Cardiol. 2003 Jun;89(2-3):239-48.	*Consider for patients with decompensated heart failure or those with accessory pathways *2nd-line agent for chronic rate control when BBs and CCBs, alone, combined, or when used with digoxin, are ineffective