When vagal maneuvers fail to terminate stable narrow-complex SVT, the primary medication of choice is adenosine. For the unstable patient with a regular and narrow QRS complex, adenosine may also be considered prior to synchronized cardioversion.
Adenosine is the primary drug used in the treatment of stable narrow-complex SVT (Supraventricular Tachycardia). Now, adenosine can also be used for regular monomorphic wide-complex tachycardia.
When given as a rapid IV bolus, adenosine slows cardiac conduction particularly affecting 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 a similar fashion. All efforts should be made to administer adenosine as quickly as possible.
A lower initial dose of 3mg should be used for patients taking dipyridamole or carbamazepine as these two medications potentiate the effects of adenosine.
Also, prolonged asystole has been seen with the use of normal doses of adenosine in heart transplant patients and central line use. Therefore, the lower dose (3mg) may be considered for patients with a central venous line or a history of heart transplant.
Precautions
Some side effects of adenosine administration include flushing, chest pain/tightness, brief asystole or bradycardia.
Make sure that adenosine is not used for irregular, polymorphic wide-complex tachycardia and unstable VT. Use in these cases may cause clinical deterioration.
Return to ACLS Drugs Main Page.
terri says
I cannot find anything to support not giving adenosine IO even though i do not see how it could possibly work.
Jeff with admin. says
I do not have any experience with this. Here is a thread from another site that may provide some insight.
Kind regards,
Jeff
Joey says
I had this conversation with an instructor who reported having success using adenosine IO in the proximal humerus.
ACLS says
Hi Joey,
Thanks so much for sharing this. I do not have any experience with regard to giving adenosine by I/O. It’s good to know that it’s a workable option.
Kind regards, Jeff
monique says
So can we give adenosine in a narrow or wide complex, as long as its regular in tachyarrythmias?
Jeff with admin. says
Yes, as long as the rhythm is regular and monomorphic.
Kind regards,
Jeff
infant with SVT says
I have read various medical sites concerning Adenosine for interruption of SVT. This site seems practical. A few questions. What is the recommended dose for an infant? What is considered a high dose for an infant?
This follows a call from a doctor who told me they ACCIDENTALLY gave my week-old baby a very high dose of Adenosine this morning due to SVT. I am quite bothered by the error, but am more interested in knowing how this could affect my child short/long-term as the hospital will always try and limit their own exposure. He mentioned it was twice the maximum dose.
Any help out there?
Jeff with admin. says
First just to let you know, adenosine is rapidly metabolized by the body. It will generally take about 20 seconds for the body to completely metabolize adenosine. This means that it is completely neutralized within 20 seconds.
Generally for the pediatric population, the dosage of adenosine is 0.1 mg per kg (initial maximum dose: 6 mg). However, if SVT conversion does not occur, the dosage can be increased. Due to the relative ease and speed with which adenosine is metabolized, I would say that your little one will be just fine. There should be no short term or long term issues.
Kind regards,
Jeff
elsafi a.hamid says
if you cannot rule out WPW syndrome confidently in wide QRS tachycardia, adenosine use is questioned. check the chest for wheeze , it happened first time wheeze might have come with the advent of SVT.
With regards
Elsafi.
dstanbery says
I did my ACLS recert today and was successful.
This site was very helpful. I went in the class with confidence.
THANKS THANKS THANKS again
Burdes says
I am confused. if Adenosine can be used for regular wide-complex tachycardia isn’t that VT? If I understand the last line says not to use for VT.
Jeff with admin. says
Adenosine cannot be used with irregular, polymorphic VT and unstable VT. Its use is very specific for wide complex VT only used on –Regular monomorphic wide-complex tachycardia.
Kind regards,
Jeff
rose says
Thank you for all your comments on adenosine. Very helpful. Thank you again
itsKevin says
According to the newest version of the ACLS for Experienced Providers Manual ( Manual and Resource text)using the AHA 2010 guidelines it states on page 161 that “Adenosine can be given as a rapid 6-mg IV push over 1 to 3 seconds through a large ( eg. antecubital) vein, followed by a 20-ml saline flush. If the arrhythmia does not convert within 1 to 2 minutes, a 12-mg bolus can be given. This second dose can be followed by another 12-mg bolus if the arrhythmia again fails to convert within 1 to 2 minutes.”
I remember when adenosine used to be 6-12-12, but believed it had changed with the new guidelines. The provider manual and the 2010 American Heart Association Guidelines for CPR and ECC manual states two doses- 6mg and 12mg.
Which information is correct? 6-12 or 6-12-12? Could this be a misprint in the Experienced Provider manual?
Thanks,
Kevin
Jeff with admin. says
I am not sure which is correct. I have looked into this matter and have not been able to determine a reason for the 6 mg and only one dose of 12 mg.
I do not see any reason why a second dose of 12 mg of adenosine should not be used and this is the way that I have always seen it used as well.
It seems reasonable for any practitioner to use a second dose of 12 mg if they thought that it was necessary.
I am just not sure at this point what I need to put on the website regarding which dosing method is correct but, adding conversations like this will help people to be familiar with the issue.
Kind regards,
Jeff
Jpsfirstresponse says
Can you go into more detail how actually adenosine works? on a more microscopic level, yes It interrupts reentry but how. Respectfully, John
Jeff with admin. says
Adenosine causes transient heart block in the AV node via Alpha-1 receptors, inhibiting adenylyl cyclase, reducing cAMP (Cyclic adenosine monophosphate) which causes cell hyperpolarization by increasing outward K+ flux. (paraphrased from Wikipedia Article on Adenosine)
Kind regards,
Jeff
John says
While Wikipedia is a nice site to visit, I would not use it as source for something like this. There have been too many inaccuracies in the past. I would only use official sources for data, especially on a site that purports to training such as ACLS. There are many official sites available that could be quoted with confidence.
Jeff with admin. says
Feel free to leave a reference to a more official site if you find one that was of value. I found the article cited to be clear, accurate, and easy to understand. This is why I referenced the Wikipedia document.
Kind regards,
Jeff
Jr Zhen says
Hi, since “adenosine is not used for irregular, polymorphic wide-complex tachycardia or VT”, can I just forget about adenosine and just give a shot of amiodarone for any VT with pulse? Thanks.
Jeff with admin. says
I would stick with the AHA ACLS Guidelines. Follow the diagram. Stable narrow complex SVT responds quite well to adenosine. Adenosine is also metabolized very fast and has fewer side effects compared to amiodarone. Kind regards, Jeff
Gaa Monyeki says
wen you are goin to do synchronised cardioversion which drug is prefered for sedation of the patient?
Jeff with admin. says
In my experience, the 3 most common medications that are used for light sedation for synchronized cardioversion are: Ativan, Versed, and Diprivan.—Kind regards, Jeff
Rhonda says
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.
Jeff with admin. says
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
Jim Easley says
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.
Robert Eberhart says
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?
Chris with admin. says
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
mooster says
My unit did some med trial studies on it before it was released in 1990. Then I personally received it for SVT, rate 220, s/p c-section. I did not respond to numerous VM attempts, IV Inderal or Pronestyl. I told the ICU doc about Adenosine . It came 20 miles by taxi from another hospital. I experienced flushing and an incredible feeling of doom when I received it but I was watching the monitor & saw a 3-4 sec pause so the doom may have come from that! It was a powerful but brief feeling so I think sedation is uncalled for & would actually make things worse with possible hypotension. I do warn pts they may have strong sensations momentarily & make sure they are not looking @ the monitor!
Helen Briggs says
Can adenosine be administered IO? Cann all drugs used in resustitation be used IO?
Chris with admin. says
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