ACLS and Adenosine
ACLS and Adenosine:
Adenosine should be used within the tachycardia algorithm when vagal maneuvers fail to terminate stable narrow-complex SVT.
Adenosine is the primary drug used in the treatment of stable narrow-complex SVT (supraventricular Tachycardia). It can now also be used for regular monomorphic wide-complex tachycardia.
When given as a rapid IV bolus, adenosine slows cardiac conduction particularly effecting conduction through the AV node. The rapid bolus of adenosine also interrupts reentry (SVT causing) pathways through the AV node and restores sinus rhythm in patients with SVT.
When injected into the body, adenosine is rapidly absorbed by red blood cells and blood vessel endothelial cells and metabolized for natural uses throughout the body. In light of this adenosine should be administered by RAPID intravenous bolus so that a significant bolus of adenosine reaches the heart before it is metabolized.
A change from the 2010 guidelines now has adenosine given up to two times rather than three.
Dosing
The first dose of adenosine should be 6 mg administered rapidly over 1-3 seconds followed by a 20 ml NS bolus. If the patient’s rhythm does not convert out of SVT within 1 to 2 minutes, a second 12 mg dose may be given in similar fashion. All efforts should be made to administer adenosine as quickly as possible.
Precautions
Some side effects of adenosine administration incude flushing, chest pain/tightness, brief asystole or bradycardia.
Make sure that adenosine is not used for irregular, polymorphic wide-complex tachycardia or VT. Use in these cases may cause clinical deterioration.
For stable wide-QRS tachycardia (with a pulse) would you use Procainamide, amiodarone and sotalol? I don’t know if you talked about this or not. At least I haven’t seen it on your site yet. Thanks.
If the rhythm is stable and I have time to seek expert consultation, this is what is recommended. In the algorithm on page 127 of the AHA provider manual, any one of the before mentioned antiarrhythmic infusions can be used. Jeff
In regards to the adenocard “nightmare” the only one I exeperienced was the first time we gave it in an ER setting and had 6 1/2 screens of flat line. That translates into about 40 seconds of asystole. The pt survived and so did we. In 20+ years of giving the drug, that certainly was the longest flat-line I have ever encountered.
Is there any literature on adenosine “nightmares” that anecdotally follow even successful use of the prep. One system I’ve work in suggested Ativan or Valium to precede the Adenocard bolus. Any thoughts?
I have never experienced, heard or read that adenosine causes nightmares. Some of the patients that I have given adenosine to say that they felt like they were going to die. Another person said that everything just started going black. I would imagine these symptoms were due to the induced bradycardia and the lack of blood flow to the brain. My own preference would be to just give the adenosine without sedation. However, for synchronized cardioversion, I prefer to sedate the patient, and most hospital protocols and ACLS guidelines recommend sedation. Even when they are sedated, I have had patients remember that it was quite painful. Hope this helps.
Chris
Can adenosine be administered IO? Cann all drugs used in resustitation be used IO?
Great question! One case report from 1996 http://www.ncbi.nlm.nih.gov/pubmed/8780485 documented adenosine successful use in an infant with an intraosseous (IO) line. Speaking from extensive personal experience, rarely are IO lines necessary for adults in the hospital setting (sometimes needed in pre-hospital setting). All cardiac arrest medications may be administered via the IO route. Adenosine has a very short half life. On an adult, adenosine’s effectiveness really depends on where the IO line is placed. If it is placed in the sternal IO position, the time to the heart may actually be shorter than a standard anticubital IV. If the IO is placed in the tibial plateau, it is much less likely that the drug will still be active by the time it reaches the heart. On infants, the distance to heart is fairly short, because they are short
There is no adult literature that describe the effectiveness of adenosine via the IO route. This would be a great experiment!
Kind regards,
Chris