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 COPDShort PM, Lipworth SI, Elder DH, Schembri S, Lipworth BJ. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ. 2011 May 10;342:d2549||#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.Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet. 1999 Jun 12;353(9169):2001-7Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85	#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