Atrial flutter is a less common cardiac arrhythmia and can be categorized as a supraventricular tachycardia (SVT), depending on the conduction ratio. In general, an intrinsic pacemaker impulse originates at the sinoatrial (SA) node within the heart’s right atrium.
During atrial flutter, an abnormal electrical circuit has developed within the atria, causing cardiac electrical impulses to follow a circular path around the right atrium. This also leads to rapid cardiac contractions, depolarizations which prevent the heart from filling adequately with blood and result in decreased cardiac output and coronary perfusion. This altered cardiac circuit controls both the heart rate and rhythm.
This rhythm has a rapid atrial rate with either a variable or fixed ventricular rate. Multiple atrial impulses per one ventricular depolarization will occur. Paroxysmal and acute cases of atrial flutter are common, whereas chronic atrial flutter is rare. This rhythm does not usually persist for extended durations of time (in comparison to atrial fibrillation), typically ceasing within minutes, hours, or days. Atrial flutter is generally considered an unstable cardiac rhythm and often transitions into atrial fibrillation.
Atrial flutter typically occurs in individuals with existing health conditions and may occur more frequently in patients with heart failure, chronic obstructive pulmonary disease (COPD), pulmonary hypertension, or heart disease. Patients experiencing this arrhythmia are at increased risk for embolism development and stroke. In addition, individuals who experience chronic recurring episodes of atrial flutter or have poorly controlled atrial flutter are at risk for heart failure or tachycardia-induced cardiomyopathy.
Risk factors for the development of atrial flutter include:
When initiating care of the conscious patient, the Advanced Cardiovascular Life Support (ACLS) Primary Assessment should be completed by the healthcare provider. The ACLS Primary Assessment describes specific actions the healthcare provider can take when caring for the conscious patient, allowing for assessment findings to guide the healthcare provider to determine appropriate measures of care. The patient’s airway, breathing, circulation, disability, and potential exposure should be evaluated. Examples of specific actions to be taken include:
Potential neurological deficits should be identified during this time, and clothing should be removed to perform a visual assessment of the patient and to search for medical alert identification or possible trauma, burns, or bleeding. Following the ACLS Primary Assessment, the healthcare provider should complete the ACLS Secondary Assessment, where H’s and T’s are considered as potential contributors to the patient’s clinical condition, a focused medical history is completed, and a differential diagnosis is established.
The cardiac rhythm and clinical condition of the patient will dictate which ACLS algorithm should be utilized to manage the patient’s care. The healthcare provider caring for an adult patient with a pulse and a tachycardic rhythm (such as atrial flutter) will reference the ACLS Adult Tachycardia With a Pulse Algorithm to implement appropriate interventions for the patient’s condition.
It is essential to recognize whether the patient is stable or unstable, as the patient’s hemodynamic stability determines which pathway the healthcare provider should follow within the algorithm to deliver appropriate interventions. Stable tachycardia will present in the patient as an increased heart rate of more than 100 beats per minute. However, the systems within the body are not working to compensate for an increased heart rate and the patient does not experience hemodynamic instability during every cardiac event.
A patient experiencing unstable tachycardia will have cardiac contractions that are uncoordinated, a heart rate that is markedly rapid (typically greater than or equal to 150 beats per minute), and they will be symptomatic and hemodynamically unstable as a result of decreased cardiac output.
When arriving to aid a conscious adult patient with a pulse, the healthcare provider should complete the ACLS Primary and Secondary Assessments, as described above. If the patient’s cardiac rhythm indicates atrial flutter, the healthcare provider should then assess whether the patient is exhibiting signs reflective of hemodynamic instability.
Signs that may present in a patient considered hemodynamically unstable may include altered mental status, hypotension, shock, ischemic chest pain, or acute heart failure. This presentation can occur due to decreased cardiac output as a result of a significantly rapid heart rate and uncoordinated cardiac contractions, which can happen in patients experiencing atrial flutter.
Once it has been determined that the adult patient is symptomatic, unstable, and experiencing tachycardia with a cardiac rhythm such as atrial flutter (as an example), the ACLS Adult Tachycardia With a Pulse Algorithm should be utilized to guide the evaluation and management of the patient.
Medications are not indicated to manage the care of patients with an unstable tachycardia (such as atrial flutter). Immediate synchronized cardioversion is indicated, however. Sedative medications should be administered before initiating cardioversion, though cardioversion should not be delayed in an unstable patient.
If a patient is hemodynamically unstable and experiencing symptoms as a result of tachycardia with a heart rate of 150 beats per minute or more, they are a candidate for cardioversion. It is important to recognize, however, that patients may be symptomatic at a heart rate less than 150 beats per minute. This may be more likely to occur if the patient has existing heart disease or other risk factors or potential contributing causes as described above. The healthcare provider should have an understanding of when cardioversion is indicated within ACLS algorithms, which medications to utilize for cardioversion, what measures to take to prepare the patient, and how to use the defibrillator. The ACLS Electrical Cardioversion Algorithm should be used to guide cardioversion as an intervention for the patient.
Unstable atrial flutter requires synchronized cardioversion, which coordinates shock delivery with the peak of the QRS complex as determined by a cardiac rhythm analysis by the defibrillator. This analysis by the device may result in a delay of the shock delivery, as it works to coordinate the timing of the shock with the R wave within the QRS complex.
While performing cardioversion, the healthcare provider should have the following equipment prepared and ready:
Sedation should be administered before initiating cardioversion, depending on the severity of the patient’s symptoms and how unstable they may be. Once preparations are complete, synchronized cardioversion should be conducted. The healthcare provider should follow recommendations specific to the available device for appropriate energy level settings for cardioversion. If the patient’s cardiac rhythm does not successfully convert following cardioversion, the healthcare provider should re-evaluate any potential underlying causes for the patient’s clinical condition. The energy level should be increased for the next cardioversion.
If a patient is hemodynamically stable with atrial flutter and does not have a wide QRS complex (greater than or equal to 0.12 seconds), beta-blockers or calcium channel blockers may be administered to manage and control the patient’s tachycardic heart rate.
Consultation with an expert is recommended for the patient experiencing atrial flutter under the ACLS Adult Tachycardia With a Pulse Algorithm. Transferring the patient to a higher level of care allows for further evaluation and treatment. Adenosine does not correct atrial flutter, though it can slow the heart rate to identify or confirm the rhythm to reveal flutter waves. Atrial flutter is typically unstable and often deteriorates into atrial fibrillation. In addition, a patient with atrial flutter is at risk of developing atrial thrombi, as these patients may alternate between atrial fibrillation and atrial flutter rhythms.
Atrial flutter is considered a supraventricular arrhythmia that has a rapid or variable ventricular rate. Multiple atrial contractions occur for each ventricular contraction.
On an ECG, atrial flutter:
Atrial fibrillation takes place as a result of deterioration in the electrical activity of the atria that contributes to the development of fibrillation. Irregular ventricular contractions occur as a result of these disorganized signals sent from the atria. A rapid heart rate occurs within this rhythm without any predictable or regular pattern, which explains why this rhythm is described as “irregularly irregular.”
On an ECG, atrial fibrillation:
Atrial flutter and atrial fibrillation can result in heart palpitations, fatigue, dizziness, lightheadedness, and thrombus development. On an ECG, atrial flutter generally has consistent and uniform activity whereas atrial fibrillation typically has coarse and irregular activity between QRS complexes.
Are you looking for additional materials to refresh or reinforce your knowledge and skills for your practice or in preparation for certification? Practice questions are available to strengthen your understanding of ACLS, Pediatric Advanced Life Support (PALS), or Basic Life Support (BLS) concepts. Additionally, summaries of cardiac rhythms that the healthcare provider should know for ACLS and PALS are available for reference and study. Study materials available to prepare you for ACLS and PALS certification exams are available here, in addition to a library of case studies.
As a healthcare provider, your patients and colleagues depend on you to identify and respond to urgent or emergent situations. These dynamic and potentially critical circumstances require you to have the knowledge and skills to lead or assist in managing the patient’s condition and care. To be ready, the education for your certification should offer both an innovative and challenging approach so that you feel confident and prepared in your ability to respond.
In addition to a thorough and rigorous education for your certification, you also need flexibility to complete the coursework. We understand that healthcare providers have demanding schedules both personally and professionally, and that flexible options are necessary to complete initial or renewal certifications in a timely manner.
The American Medical Resource Institute (AMRI) supports healthcare providers seeking ACLS, PALS, or BLS certifications by offering a convenient learning environment where students can complete the certification coursework and exam on any device, with an accommodating schedule. Once the online certification program and provider exam are finished, the student can complete the clinical skills portion of the course at their workplace, where an educator or clinical supervisor can verify and document the student’s clinical skills.
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