ATRIAL FLUTTER IN A HAEMODYNAMICALLY UNSTABLE PT---

WHICH OF THE FOLLOWING IS THE INITIAL TREATMENT-MODALITY??
1)DC-cardioversion with 360 Joules
2)DC-cardioversion with 50 Joules
3)IV Verapamil
4)IV Esmolol

atrial flutter has an atrial rate of 250 to 350 beats per mt and ventricuklar rate is around 150 beats per mtalthough atrial rate can be slowed by dc cardioversion of low power bt the chances of conversion to atrial fibrillation r more when low dc cardioversion of 50 joules used.so higher energies preferred.if patients clinical status not unstable then first ventricular rate can be slowed by using digitalis,betablocker i,e iv esmolol or iv verapamil.so answer is dc cardioversion with 360 joules.reference page 1347 harrison 16th