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Management of Atrial Fibrillation

Question# 770

I seem to frequently see patients in 911 calls that are symptomatic for accelerated/uncontrolled a-fib or other irregular tachydysrhythmias, more commonly than regular. Given our tachydysrhythmia standing orders only allow interventions for regular rhythms, I usually feel limited to my intervention options. Is there a role for any antiarrhythmics I carry, and if not, is there discussion about including short-acting beta blockers in the ACP scope in the future?


You are correct in stating that the Tachydysrhythmia Medical Directive states that we are treating only regular rhythms with antiarrhythmics. If your patient is presenting with an irregular tachydysrhythmia and you believe they require treatment outside of the medical directives, then a consult with a BHP is necessary. However, if your patient is pre-arrest and requires cardioversion, and the rhythm is irregular, this is within your scope of practice to do without consultation with a BHP. There are however some main concerns with treating atrial fibrillation/irregular rhythms prehospitally, mainly thromboembolism, as these patients may not have been anti-coagulated prior to treatment and often rapid atrial fibrillation is secondary to a different cause that requires treatment beyond simply managing the rhythm alone. A.Fib is a complex entity and needs a complete assessment to determine the cause (primary or secondary).

Many people have a reason for developing acute episodes of A.Fib, which includes PE, ACS, dehydration, infection, etc. and treating the underlying cause often improves the A.Fib. Thus, other interventions aside from antiarrhythmics include IV fluid therapy, analgesia, and/or patching for antipyretics (if fever is considered a factor) all of which may control the rate or even convert the patient to a normal sinus rhythm.

There is some literature that states an amiodarone bolus followed by an infusion had positive outcomes in reducing ventricular rates in some atrial fibrillation patients. However, it has to be the right patient, who has a history of A.Fib/A.Flutter, in a primary arrythmia without secondary cause, is fully anticoagulated and compliant with anticoagulation, is very symptomatic (SOB/Chest Pain/Respiratory Distress), is not unstable enough for synchronized cardioversion, and often a considerable distance to hospital. Amiodarone works as a rate controller from the beta-blockade, which controls the rate-related symptoms, and can also cardiovert the patient out of the A.Fib/A.Flutter.

There is currently no evidence surrounding the use of Lidocaine prehospitally for atrial fibrillation as it is only effective on ventricular arrhythmias.

In conclusion, prehospitally we should focus on what we can offer such as synchronized cardioversion for peri-arrest patients due to unstable primary tachycardias (which is rarely required for A.Fib/A.Flutter) and treat the secondary causes of rapid A-fib/flutter, like fluids for dehydration and sepsis, analgesia for pain, and consider patching for antipyretics if a fever is a factor.


Medical Directive Category



24 January 2024

ALSPCS Version




Please reference the MOST RECENT ALS PCS for updates and changes to these directives.