Diltiazem 0.25mg/kg IV (20mg) followed in 15 minutes by 0.35mg/kg IV (25mg) if no response
-Used for rate control
-Preferred over Verapamil as may have less inotropic depression with less hypotension
-Administer over 5 minutes (not push) to decrease chance of hypotension
-Treat hypotension with calcium gluconate 5cc IV
-May pretreat with calcium gluconate 5cc IV to prevent hypotension
-If effective, follow by a drip at 5-15mg/hour
-Start dosing lower if elderly/in CHF/hypotensive
Verapamil 2.5-5.0mg IV followed in 30min by 5-10mg IV if no response
-Used for rate control
-May cause more hypotension than diltiazem
-Drip at 5mg/hour for maintenance
-Start dosing lower if elderly/in CHF/hypotensive
-Not used very commonly
Esmolol 500mcg/kg IV bolus over 1min then 50-200 mcg/kg/min IV drip
-Used for rate control
-Especially useful for pts with AMI or thyrotoxicosis
-Repeat bolus and increase drip as needed
-Caution in pts with severe RAD or active wheezing
-Half-life is approximately 9 minutes
Metoprolol (Lopressor) 5mg IV q5 min until rate control achieved
- Used for rate control
-Especially useful for pts with AMI or thyrotoxicosis
-Caution in pts with severe RAD or active wheezing
Digoxin not used in the acute setting.
-Check a level if pt already on this medication
Amiodarone 150mg IV over 10min
-Not FDA-approved for rate control of supraventricular tachycardias
-Wide range of reported efficacies
-Less efficacious than diltiazem and magnesium for rate control and conversion
-Very little predisposition to hypotension as even less negative inotropy than diltiazem
Magnesium 2-4gm IV over 30 minutes
-Preliminary investigations suggest better rate control and conversion than dilt and amio
Heparin IV or Lovenox SQ administration in the ED is controversial.
ED conversion to NSR is VERY controversial.
-Only do in consultation with Cardiology or Internal Medicine