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Unstable atrial fibrillation with pulmonary oedema — SCE Acute Medicine MCQ

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EasyAcute Cardiac PresentationsUnstable atrial fibrillation with pulmonary oedemaSCE Acute Medicine

A 69-year-old man develops palpitations and breathlessness on the AMU. ECG shows atrial fibrillation at 168 bpm. BP is 78/46 mmHg, he is clammy with pulmonary oedema on auscultation, and symptoms began around three hours ago. What is the most appropriate next step in management?

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Correct answer: E — Perform synchronised electrical cardioversion

Atrial fibrillation with shock and pulmonary oedema is an unstable tachyarrhythmia, so immediate synchronised cardioversion is indicated. Oral beta-blockade and digoxin are too slow and may worsen instability. Delayed elective cardioversion applies to stable AF of longer or uncertain duration. Adenosine is used diagnostically or therapeutically for regular narrow-complex tachycardia, not unstable AF.

Reference: Resuscitation Council UK ALS guidelines, NICE NG196