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In haemodynamically stable patients where atrial fibrillation is known to be of recent onset (<48 hours) and not precipitated by intercurrent illness, the patient should undergo electrical cardioversion. If that fails, pharmacological cardioversion should be attempted. Amiodarone is both antiarrhythmic and rate limiting (see below for dosing regimen). 5 mg in divided doses over 24 hours), particularly in the presence of left ventricular dysfunction, and beta-blockers. Long-term antithrombotic treatment is not required if a patient is thought to be at low risk of recurrence of atrial fibrillation after restoration of sinus rhythm.

32 MMC Core Curriculum Excluding cardiac syncope as the cause of collapse is important as these patients have a higher mortality than those with noncardiac causes. Epilepsy If the patient was awake during an attack, ask specifically about any warnings that he or any witness may have noticed. Features such as lip smacking, fiddling with clothes or stereotyped movements would be It will clearly also be important to get a more detailed history of the patient’s other medical conditions and of the wider social picture: organising appropriate discharge and placement for a man with mild dementia and Parkinson’s disease who has fallen at home may not be straightforward.

Drowsiness or confusion. MMC Core Curriculum 23 AM_C01 12/15/10 10:16 Page 24 ACUTE MEDICINE: PACES STATIONS AND ACUTE SCENARIOS ›Fig. 10 Echocardiogram of a ventricular septal defect following MI (a) and the flow across the defect (b). LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. Management of a tachyarrhythmia associated with adverse features should include the following. • • • • • Call for help immediately. Give high-flow oxygen. Apply cardiac monitor. Insert intravenous access.

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