Extracts from 2010 CPR & ECC Science – Medications – Adenosine
by Alan Batt. Last modified: 12/08/14
In this series of posts we will take extracts on medications and interventions from the 2010 CPR & ECC Guidelines and provide the links to their PubMed abstracts where available. We will also indicate which ones are available through open-access. A similar format is available directly through Circulation online (link below), but this does not utilise opening links through Read by QxMD.
Part 8: Adult Advanced Cardiovascular Life Support
If PSVT does not respond to vagal maneuvers, give 6 mg of IV adenosine as a rapid IV push through a large (eg, antecubital) vein followed by a 20 mL saline flush (Class I, LOE B). If the rhythm does not convert within 1 to 2 minutes, give a 12 mg rapid IV push using the method above.
Because of the possibility of initiating atrial fibrillation with rapid ventricular rates in a patient with WPW, a defibrillator should be available when adenosine is administered to any patient in whom WPW is a consideration. As with vagal maneuvers, the effect of adenosine on other SVTs (such as atrial fibrillation or flutter) is to transiently slow ventricular rate (which may be useful diagnostically) but not afford their termination or meaningful lasting rate control.
A number of studies381–398 support the use of adenosine in the treatment of stable PSVT. Although 2 randomized clinical trials383,386 documented a similar PSVT conversion rate between adenosine and calcium channel blockers, adenosine was more rapid and had fewer severe side effects than verapamil. Amiodarone as well as other antiarrhythmic agents can be useful in the termination of PSVT, but the onset of action of amiodarone is slower than that of adenosine,399 and the potential proarrhythmic risks of these agents favor the use of safer treatment alternatives.
Adenosine is safe and effective in pregnancy.400 However, adenosine does have several important drug interactions. Larger doses may be required for patients with a significant blood level of theophylline, caffeine, or theobromine. The initial dose should be reduced to 3 mg in patients taking dipyridamole or carbamazepine, those with transplanted hearts, or if given by central venous access. Side effects with adenosine are common but transient; flushing, dyspnea, and chest discomfort are the most frequently observed.401 Adenosine should not be given to patients with asthma.
After conversion, monitor the patient for recurrence and treat any recurrence of PSVT with adenosine or a longer-acting AV nodal blocking agent (eg, diltiazem or b-blocker). If adenosine or vagal maneuvers disclose another form of SVT (such as atrial fibrillation or flutter), treatment with a longer-acting AV nodal blocking agent should be considered to afford more lasting control of ventricular rate
381.DiMarco JP1, Miles W, Akhtar M, Milstein S, Sharma AD, Platia E, McGovern B, Scheinman MM, Govier WC. Adenosine for paroxysmal supraventricular tachycardia: dose ranging and comparison with verapamil. Assessment in placebo-controlled, multicenter trials. The Adenosine for PSVT Study Group. Ann Intern Med. 1990 Jul 15;113(2):104-10. PMID: 2193560.
382.Lim SH1, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009 May;80(5):523-8. PMID: 19261367.
385.Rankin AC1, Oldroyd KG, Chong E, Dow JW, Rae AP, Cobbe SM. Adenosine or adenosine triphosphate for supraventricular tachycardias? Comparative double-blind randomized study in patients with spontaneous or inducible arrhythmias. Am Heart J. 1990 Feb;119(2 Pt 1):316-23. PMID: 2405610.
387.Morrison LJ1, Allan R, Vermeulen M, Dong SL, McCallum AL. Conversion rates for prehospital paroxysmal supraventricular tachycardia (PSVT) with the addition of adenosine: a before-and-after trial. Prehosp Emerg Care. 2001 Oct-Dec;5(4):353-9. PMID: 11642584.
388.Glatter KA1, Cheng J, Dorostkar P, Modin G, Talwar S, Al-Nimri M, Lee RJ, Saxon LA, Lesh MD, Scheinman MM. Electrophysiologic effects of adenosine in patients with supraventricular tachycardia. Circulation. 1999 Mar 2;99(8):1034-40. PMID: 10051297.
391.Gausche M1, Persse DE, Sugarman T, Shea SR, Palmer GL, Lewis RJ, Brueske PJ, Mahadevan S, Melio FR, Kuwate JH, et al. Adenosine for the prehospital treatment of paroxysmal supraventricular tachycardia. Ann Emerg Med. 1994 Aug;24(2):183-9. PMID: 8037382.
392.McIntosh-Yellin NL1, Drew BJ, Scheinman MM. Safety and efficacy of central intravenous bolus administration of adenosine for termination of supraventricular tachycardia. J Am Coll Cardiol. 1993 Sep;22(3):741-5. PMID: 8354807.
393.Riccardi A1, Arboscello E, Ghinatti M, Minuto P, Lerza R. Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002-2006). Am J Emerg Med. 2008 Oct;26(8):879-82. PMID: 18926344.
394.Sellers TD, Kirchhoffer JB, Modesto TA. Adenosine: a clinical experience and comparison with verapamil for the termination of supraventricular tachycardias. Prog Clin Biol Res. 1987;230:283-99. PMID: 3295883.
398.Madsen CD1, Pointer JE, Lynch TG. A comparison of adenosine and verapamil for the treatment of supraventricular tachycardia in the prehospital setting. Ann Emerg Med. 1995 May;25(5):649-55. PMID: 7741343.
399.Cybulski J1, Kułakowski P, Makowska E, Czepiel A, Sikora-Frac M, Ceremuzyński L. Intravenous amiodarone is safe and seems to be effective in termination of paroxysmal supraventricular tachyarrhythmias. Clin Cardiol. 1996 Jul;19(7):563-6. PMID: 8818437.
Part 14: Pediatric Advanced Life Support
Pharmacologic cardioversion with adenosine is very effective with minimal and transient side effects.300–304 If IV/IO access is readily available, adenosine is the drug of choice. Side effects are usually transient.300–304 Administer IV/IO adenosine 0.1 mg/kg using 2 syringes connected to a T-connector or stopcock; give adenosine rapidly with 1 syringe and immediately flush with 5 mL of normal saline with the other. An IV/IO dose of Verapamil, 0.1 to 0.3 mg/kg is also effective in terminating SVT in older children,305,306 but it should not be used in infants without expert consultation (Class III, LOE C) because it may cause potential myocardial depression, hypotension, and cardiac arrest.306,307
302. Moghaddam M, Mohammad Dalili S, Emkanjoo Z. Efficacy of Adenosine for Acute Treatment of Supraventricular Tachycardia in Infants and Children. J Teh Univ Heart Ctr. 2008;3:157–162. Link: http://jthc.tums.ac.ir/index.php/jthc/article/view/96
303.Riccardi A1, Arboscello E, Ghinatti M, Minuto P, Lerza R. Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002-2006). Am J Emerg Med. 2008 Oct;26(8):879-82. PMID: 18926344.
304.Ertan C1, Atar I, Gulmez O, Atar A, Ozgul A, Aydinalp A, Müderrisoğlu H, Ozin B. Adenosine-induced ventricular arrhythmias in patients with supraventricular tachycardias. Ann Noninvasive Electrocardiol. 2008 Oct;13(4):386-90. PMID: 18973496.
305.Lim SH1, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009 May;80(5):523-8. PMID: 19261367.
306.Holdgate A1, Foo A. Adenosine versus intravenous calcium channel antagonists for the treatment of supraventricular tachycardia in adults. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005154. PMID: 17054240.
307.The following two tabs change content below.Paramedic, educator, researcherAlan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.
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Extracts from 2010 CPR & ECC Science – Medications – Adenosine
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