Doctor world

1. Admit to:
2. Diagnosis: Atrial fibrillation
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing:
7. Diet:
8. IV fluids:
9. Special medications:Cardioversion (if unstable or refractory to drugtreatment):
If unstable, perform synchronized cardioversion using 0.5 J/kg immediately. In stable patient with atrial fibrillation, consider starting quinidine or procainamide 24-48h prior to cardioversion.
-Quinidine gluconate 2-10 mg/kg/dose IV q3-6h
-Procainamide: loading dose: 3-6 mg/kg IV over 5 min (max 100 mg), may repeat every 5-10 minutes to max of 15 mg/kg (max 500 mg). Maintenance: 2080 mcg/kg/min continuous IV infusion (max 2 gm/24 hrs).
-Midazolam (Versed) 0.1 mg/kg (max 5 mg) IV over 2
min, repeat prn until amnesic. Synchronized cardioversion using 0.5 J/kg.Increase stepwise by 0.5 J/kg if initial dosage fails to convert the patient. Consider esophageal overdrive pacing.
Digoxin Rate Control: Initial digitalization is given over 24 hours in three divided doses: 1/2 total digitalizing dose (TDD) at time 0 hours, 1/4 TDD at 8-12 hours, and 1/4 TDD 8-12 hours later. Maintenance therapy is then started. IM administration not recommended due to local irritation, pain, and tissue damage.
Total Digitalizing Dose
Premature infantTerm neonate (0-4 weeks)1-23 months2-4.99 years5-10 years11-17 years>17 years
Maintenance digoxin dose
Premature infantTerm neonate (0-4 weeks)1-23 months2-4.99 years5-10 years11-17 years>17 years
POIV/IM
20-30 mcg/kg15-30mcg/kg25-35 mcg/kg20-25mcg/kg40-50 mcg/kg30-50mcg/kg30-40 mcg/kg25-35mcg/kg20-35 mcg/kg15-30mcg/kg10-15 mcg/kg8-12mcg/kg0.75-1.5 mg0.5-1 mg
PO IV/IM4-12 mcg/kg/day4-9mcg/kg/day6-10 mcg/kg/day 5-8mcg/kg/day7.5-12 mcg/kg/day8-10mcg/kg/day8-10 mcg/kg/day 6-8mcg/kg/day5-10 mcg/kg/day4-8mcg/kg/day2.5-5 mcg/kg/day 2-3mcg/kg/day0.125-0.5 mg/day 0.10.4 mg/day
Divide bid if <10>10 years.[caps: 50, 100, 200 mcg; elixir: 50 mcg/mL; inj: 100mcg/mL, 250 mcg/mL; tabs: 0.125, 0.25, 0.5 mg].
Other Rate Control Agents: -Propranolol 0.01-0.1 mg/kg slow IV push over 10 minutes,repeatq6-8h prn (max 1 mg/dose) or 0.5-5 mg/kg/day PO q6-8h (max 60 mg/day) [inj: 1 mg/mL; oral solutions: 4 mg/mL, 8 mg/mL; oral concentrate: 80 mg/mL; tabs: 10, 20, 40, 60, 80 mg].
Pharmacologic Conversion (after rate control): -Procainamide (Pronestyl): Loading dose of 3-6 mg/kg/dose IV over 5 min, then 20-80 mcg/kg/min IV infusion (max 100 mg/dose or 2 gm/24h). Oral maintenance: 15-50 mg/kg/day PO q3-6h (max 4 gm/day). [caps: 250, 375, 500 mg; inj: 100 mg/mL, 500 mg/mL; tabs: 250, 375, 500 mg; tabs, SR: 500, 750, 1000 mg].
10. Extras and X-rays: Portable chest X-ray, ECG, echocardiogram.
11. Labs: CBC, SMA 7, Mg, Ca, UA, ABG. Serum drug levels.