Case-Based Modules > Case 24 > Stage 2

This is a good textbook answer-- the patient is hypotensive and is in a-fib with RVR with a ventricular rate between the 160s-180s. Their RVR is definitely a big contributor to their hypotension right now. So, if one concept is reinforced from this case, then it's good to focus on managing unstable a-fib with synchronized cardioversion.

It's worth discussing that the option of loading with IV amiodarone and starting the continuous infusion is actually also very reasonable at this stage, though. This patient has a large MCA infarct with some petechial hemorrhaging, so we may not want to necessarily start therapeutic anticoagulation just yet. Electrical cardioversion can cause myocardial stunning; it's probably more likely to cause this than chemical cardioversion. So, while we'd want to initiate therapeutic anticoagulation after either DCCV or amiodarone, and can't in this case just yet, choosing the former may pose a theoretically higher risk of causing further thromboembolic events with delays in anticoagulation initiation.

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