PLACE LABEL HERE
ATRIAL FIBRILLATION ORDERS
Emergency Department
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1.
2.
Diagnosis & Status: Place in Observation for Atrial Fibrillation
Private Physician:  None  ___________________________ Time Contacted: _________________
Consults: __________________________________________________________________________
3.
Laboratory: Magnesium if not done in ED
 Chem 7 if not done in ED  Digoxin level
 PT, PTT if patient on Coumadin  TSH
 Other: ___________________________________________________________________
4. Radiology: CXR  Portable
 PA and Lateral
Clinical indication: shortness of breath, new onset atrial fibrillation
5.  Echocardiogram. Clinical indication: new onset atrial fibrillation
6. Continuous cardiac monitoring (for at least 4 hrs post conversion if converted by Corvert {ibutilide})
 May be off telemetry for tests and transport
7. Vital signs:  q 4 hrs
 q ______ hrs
8. Notify physician for:
 Potassium < 4 prior to Corvert (ibutilide) administration
 Magnesium < 2 prior to Corvert (ibutilide) administration
 QTc interval > 500 millimeters

 QTc interval widening of > 25% from baseline occurs during or after Corvert (ibutilide) administration
 Failure to convert to NSR one hr after Corvert (ibutilide) administration
 Chest Pain, Systolic BP < 90 mm HG, Heart rate > 130 or < 55
9. Diet:  NPO  Clear liquids  Regular  __________________ Consistent Carb diet
10. Activity (advance as tolerated):  Bed rest
 Bedside Commode
 Bathroom privileges
 Up ad lib  Up with assistance
HOME MEDICATION ORDERS: to be administered while in the observation:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Send copy to pharmacy
*3-16338*
Order writer’s initials _________
FORM 3-16338 REV. 07/2012
Page 1 of 2
PLACE LABEL HERE
ATRIAL FIBRILLATION ORDERS
Emergency Department
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
SCHEDULED MEDICATIONS:
11.  INT
 IVF __________________________________________ IV at ______________ ml/hr
12. Rate Control:  Digoxin ______________________ mg IV x 1 dose, then ______________________
 CardiZEM (diltiazem) _____________ mg IV x 1 dose, then ____________________
 Other: ______________________________________________________________
13. Cardioversion:  Weight > 60 kg (132 lbs): Corvert (ibutilide) 1 mg (10 ml) IV over 10 min
Repeat dose 10 min after initial infusion if patient does not convert to
Normal Sinus Rhythm (NSR)
 Weight < 60 kg (132 lbs): Corvert (ibutilide) 0.01 mg/kg for IV over 10 min
Repeat 10 min after initial infusion if patient does not convert to NSR
14. Potassium replacement:  KCL 20 mEq IVPB over 2 hr x 1 dose while on continuous monitoring
15. Magnesium replacement:  Magnesium Sulfate 1 gm IVP over 1 hr x 1 dose
PRN MEDICATIONS (If > one drug is ordered for the same indication, clinical assessment will be used per policy 520-06)
16.
Moderate Pain:
 Lortab (HYDROcodone/acetaminophen) 5/500 mg 1-2 tabs or 10/500 mg 1 tab po q 4 hrs prn
 Percocet (oxyCODONE/acetaminophen) 5/325 mg 1-2 tabs or 10/325 mg 1 tab po q 4 hrs prn
 Hycet elixir (HYDROcodone 7.5 mg / acetaminophen 325 mg/15 ml) 15 ml po q 4 hrs prn

 Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if > 65 y/o old or < 50 kg)
or 10 mg po q 6 hrs prn (max combined duration of IV and po Toradol {ketorolac} is 5 days)
17.
Mild Pain, Temp >100.5
18.
Nausea/Vomiting:
 Zofran (ondansetron) 4 mg IV or po q 6 hrs prn
 Reglan (metoclopramide) 10 mg IV or po q 6 hrs prn (5 mg if > 65 y/o)
 Phenergan (promethazine) 12.5-25 mg po or per rectum q 4 hrs prn
19.
Sleep:  Ambien (zolpidem) 5-10 mg po at HS prn. If 5 mg given, may repeat x 1 dose after 2 hrs
If > 65 year old, begin with 5 mg po at HS, may repeat x 1 dose after 2 hrs
 Other: ___________________________________________________________________
20.
Anxiety:
 Ativan (lorazepam) 0.5 - 1 mg po q 8 hrs prn
 Xanax (alprazolam) 0.25 - 0.5 mg po q 6 hrs prn
ADDITIONAL ORDERS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________
Date
___________________
Time
_________________________________
Physician Signature
___________
PID Number
Send copy to pharmacy
FORM 3-16338 REV. 07/2012
Page 2 of 2