CJEM Articles: cardioversion

Displaying 1-3 of 3 results

  • Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter
    May 2010 12 3
    Catherine M. Clement, Cheryl Symington, Christian Vaillancourt, David Birnie, Garth Dickinson, Ian G. Stiell, Jeffrey J. Perry, Martin S. Green

    Objective: There is no consensus on the optimal management of recent-onset episodes of atrial fibrillation or flutter. The approach to these conditions is particularly relevant in the current era of emergency department (ED) overcrowding. We sought to examine the effectiveness and safety of the Ottawa Aggressive Protocol to perform rapid cardioversion and discharge patients with these arrhythmias.

    Methods: This cohort study enrolled consecutive patient visits to an adult university hospital ED for recent-onset atrial fibrillation or flutter managed with the Ottawa Aggressive Protocol. The protocol includes intravenous chemical cardioversion, electrical cardioversion if necessary and discharge home from the ED.

    Results: A total of 660 patient visits were included, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procainamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procainamide and 6.5 hours for those requiring electrical conversion.

    Conclusion: This is the largest study to date to evaluate the Ottawa Aggressive Protocol, a unique approach to cardioversion for ED patients with recent-onset episodes of atrial fibrillation and flutter. Our data demonstrate that the Ottawa Aggressive Protocol is effective, safe and rapid, and has the potential to significantly reduce hospital admissions and expedite ED care.

  • Cardioversion of uncomplicated paroxysmal atrial fibrillation: a survey of practice by Canadian emergency physicians
    May 2004 6 3
    Bjug Borgundvaag, Howard Ovens

    Objective: Paroxysmal atrial fibrillation (PAF) is the rhythm disturbance most commonly encountered by emergency physicians, yet the role played by emergency physicians in the management of this condition has not been well described. The purpose of this study was to describe the management of uncomplicated PAF by Canadian emergency physicians.

    Methods: All members of the Canadian Association of Emergency Physicians with a Canadian address (n = 1255) were mailed a 15-point questionnaire regarding training/certification, hospital demographics and practice patterns regarding the management of uncomplicated PAF. Chi-squared analysis and Fisher's Exact test were performed to identify significant differences in reported practice patterns in relation to demographic variables. Significant associations were tested for interaction using the Mantel-Haenszel test.

    Results: We received 663 responses, representing a 52.8% response rate. Six hundred and twenty-two (95%), 514 (78%) and 242 (38%) respondents reported routine performance of rate control, chemical cardioversion and electrical cardioversion respectively. Physicians working in high-volume emergency departments (

    >50 000 visits/yr) were significantly more likely to self-manage rate control and chemical/electrical cardioversion than those working in lower volume emergency departments. Residency training was associated with higher performance of electrical (44% v. 31%, p

    < 0.01) but not chemical cardioversion or rate control, although, amongst residency trained physicians, those with FRCP-level training were significantly more likely to perform both chemical (86% v. 76%, p

    < 0.05) and electrical (57% v. 37%, p

    < 0.01) cardioversion.

    Conclusion: Canadian emergency physicians surveyed in this study actively manage uncomplicated PAF. We found significant variations in practice, especially related to the use of electrical cardioversion. This may reflect different practice environments, levels of training, and lack of evidence to guide best practice. Further research is required to determine the optimal care of PAF in the emergency department setting.

  • Is propofol an optimal agent for procedural sedation and rapid sequence intubation in the emergency department?
    October 2001 3 4
    Kerry Wilbur, Peter J. Zed

    Objective: We conducted a qualitative systematic review to evaluate the efficacy and safety of propofol for direct current cardioversion (DCC), rapid sequence intubation (RSI) and procedural sedation in adult emergency department (ED) patients.
    Data source: MEDLINE (1966 to September 2000), PubMed (to September 2000), EMBASE (1988 to September 2000), Database of Systematic Reviews (to September 2000), Best Evidence (1991 to September 2000) and Current Contents (1996 to September 2000) databases.
    Study selection: English-language, randomized, comparative evaluations of propofol for procedures routinely conducted in adults (>18 years) were included. Direct current cardioversion, RSI and procedural sedation were considered.
    Data extraction: Efficacy and safety endpoints were evaluated for all trials. For DCC and procedural sedation trials, efficacy measures included induction and recovery times, as well as the association for successful procedure. For the RSI trials, optimal intubating conditions were evaluated as the primary efficacy endpoint. Safety measures included hemodynamic changes, apnea rates and adverse effects.
    Data synthesis: In the setting of DCC, efficacy and safety outcomes were similar for propofol, thiopental, etomidate and methohexital. All of these agents provided markedly shorter induction and recovery times than midazolam. Patients who were pre-medicated with fentanyl exhibited prolonged recovery times and greater decreases in blood pressure. When used for RSI, propofol administration was associated with satisfactory intubating conditions that were comparable to those seen with thiopental and etomidate. Blood pressure reductions were seen in both DCC and RSI studies. Apneic episodes (>30 seconds) occurred in 23% of propofol recipients, 28% of thiopental recipients and 7% of etomidate and midazolam recipients. Apart from the DCC studies described, no procedural sedation studies met our predefined review eligibility criteria.
    Conclusion: The body of literature evaluating propofol for DCC and RSI in the ED is limited. There is evidence to support the use of propofol for DCC and RSI, but this evidence comes from stable patients in non-ED settings. Further ED-based randomized comparative trials should be conducted before propofol is adopted for widespread use in the ED.