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 doses	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