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.
Barbara says
This was done to me when I went in to SVT tach and I couldn’t get it back to normal. It felt awful for about six seconds then heart went back to normal. That was on the first 6 mg. I am having an ablation on the first of May. I hope I am one of the 98 percent that will never have to deal with SVT again. My doc was wonderful when I had the Adenosine. She held my hand as I was terrified. The staff experience was terrific. I felt kind of tired for a few days after. I was told that is normal.
Jeff with admin. says
Treatment with adenosine can be a very scary thing. I had one person who told me they felt like they were dying when they received adenosine.
I hope that your ablation goes well.
Kind regards,
Jeff
Mary Alar-Hogger says
I have a question. In the patient that the initial dose is 3mg and a second dose is needed would you then progress to the 6mg and stop there, or move up to a 12 mg dose?
Jeff with admin. says
You would increase incrementally. It would be appropriate to do 3-6-12 or 3-6-6.
Kind regards,
Jeff
abdulrasyid says
For SVT some one use 10 mg -20 mg – ATP accordingly. When first and second dose fail to convert the arythmia to sinus rythme the third dose was given and success.. My question can we give more dose of ATP several minutes after the third dose in case the third dose fail? How much max dose of ATP?
Jeff with admin. says
Adenosine is usually given no more than 3 times. This is because if adenosine is going to work, it will work within the first 3 attempts. However, there would be no contraindication to giving another dose adenosine since it is rapidly metabolized by the body. Kind regards, Jeff
mohamed ashry says
why adenosine is given as single dose and not repeated freqently
Jeff with admin. says
Because if adenosine is going to work, it will almost always work within the first or second dose. Adenosine can be repeated as follows 6mg then 12mg then 12mg again. AHA only lists 6 and 12, but you can give the 3 doses safely. If the rhythm has not converted within 3 doses then it is very unlikely that adenosine will successfully convert the tachyarrhythmia.
Kind regards,
Jeff
Bruce says
One of our fellow RNs claims that when using a central line, you only use half the normal dose of adenosine,IE: 3mg instead of 6mg. Has anybody else heard about this? Many of us have recently completed our ACLS recerts and none of us had heard this. This RN is convinced that this is the case.
Jeff with admin. says
The RN who believes that 3mg is used is mistaken. The recommended dose whether given with a peripheral line or a central line is 6mg.
Kind regards,
Jeff
Geo says
Please refer to AHA handbook on page 39 which states to reduce the dosage of Adenosine to 3 mg for three different reasons. Refer to AHA ACLS manual on page 129. This is not new as it has been in the last three AHA textbook editions.
Sincerely,
Geo
Jeff with admin. says
Thank you for pointing this out. This is correct. The 3mg dose should be used for the following situations: A lower initial dose of 3mg shoud 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.
Kind regards,
Jeff
jolly says
Bruce, the RN is right. If a central line is used or even in patients who had heart transplant or are on carbamazepine the dose is 3 mg. It is mentioned in the 2010 AHA ACLS updates which is in the journal circulation. The article can be downloaded
here is the link http://circ.ahajournals.org/content/122/18_suppl_3/S729.full.pdf+html
Jeff with admin. says
Thank you for pointing this out. This is correct. The 3mg dose should be used for the following situations: A lower initial dose of 3mg shoud 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.
Kind regards,
Jeff
Peter Bonadonna, EMT-P says
Regarding Adenosine dosing: You should start with 3 mg if you are using a central line. The 6 mg dose takes into account peripheral administration and that adenosine is absorbed by RBCs and every cell in the body at a rapid rate. It is wise to start with a smaller dose when you are bypassing most of the circulation. Many reliable medical authorities recommend this.
Jeff with admin. says
Thank you for pointing this out.
Kind regards,
Jeff
Peter Bonadonna, EMT-P says
This monograph is from the manufacturer of Adenosine recommending a reduced dose with a central line.
http://www.drugs.com/monograph/adenosine.html
sherry says
AHA tells us to cut the dose in half, to 3mg when using a CENTRAL LINE, there is a reason, It will reach the AV node more quickly because of where the line is located, nearer to the heart in the large vessels. The medicine is carried more quickly by the bloodstream, and therefore doesn’t have the chance to deteriorate the effectiveness of the medication by being metabolized before it reaches it’s intended target. In other words, Adenosine metabolizes quickly, and you don’t want it to lose it’s effectiveness by traveling a longer way thru the bloodstream before reaching the AC nodal area. That is also why you follow your Adenosine IV with 20cc NS bolus to push it more quickly toward the intended target.
LT says
I work in an outpatient facility and we have many small clinics that have crash carts available. This question may seem very trivial and petty, but I have some staff who have differing opinions on administering Adenosine. Adenosine needs to be followed by 20 ml of Normal Saline. At our facility we try to keep minimal, but necessary supplies on hand. A few of our staff believe that 2 10 ml normal saline flush will suffice for giving a bolus dose (take into consideration syringe switching) and a few other staff members feel that we should only use a 20 ml syringe of Normal Saline to follow the administration of adenosine (take into consideration the time it will take to draw this up). Which is correct? Could either method be used?
Jeff with admin. says
It would be better to use one 20 ml syringe. The half life of adenosine is only several seconds so the adenosine should be pushed very very rapidly and followed with 20 ml NS pushed as rapidly as possible. Actually, the best way to push adenosine is to have a 3 way stopcock. One line to the patient, one line with Adenosine, and one line with NS. Push the NS and after the push rapidly change the stop position of the NS to open and then rapidly push the NS. This will eliminate having to unscrew the adenosine syringe and screw on the NS syringe.
The faster the adenosine can be pushed, the more likely it is to have the desired effect.
I hope that makes sense.
Kind regards,
Jeff
Yousuma says
I was taught to use a y type IV. You can push adenosine and then saline. You must remember to hold pressure on the opposite plunger.
Jeff with admin. says
Thank you for the suggestion. Your technique would be good in this situation. Kind regards, Jeff
Catherine says
Yes! Exactly how it was administered to me. This was what the paramedics were taught and it was performed beautifully and effectively. Third time was a charm????
francisco says
The feeling of this drug entering your bady is very overwleming, it feels like you loose all control and your body is slowly shutting down.At one point I thought i started to see black, the experience is painless but hurts at the same time, like hitting your funny bone exept its all over your body.It feels like its in you for hrs but in reality only 30 seconds have past.One of the worst experiences i have gone through, all i recommend is take long deep breaths, panicing does not help i learned the hard way. Had the drug pumped in my 3 times now.
Brett says
Had a 2 year old in SVT tonight who has WPW. We gave her 1.6 of Adenosine with no change and then 3.2 and she converted nicely. First pediatric I’ve ever converted so was a bit scary but thankfully everything went well.
Best,
Brett
Jeff with admin. says
Wow! Sounds very interesting. Thank you for sharing that.
Kind regards, Jeff
Jackie says
I recently went on a call where the patient was found in SVT heart rate of 212 upon EMS arrival. The patient initially denied the use of recreational drugs. After 6 mg adenosine the pt went into a short run of VTACH, then a weird rhythm for another 10 seconds before going into NSR. En route to the hospital pt admitted to using Meth approx. 4-5 hours prior the chest discomfort. But her family also has an extensive cardiac history. I was curious if the meth caused the SVT or if the meth could have caused the VTACH or what your theory might be.
Jeff with admin. says
I’m not sure, but my educated guess would be that the meth caused the SVT and the weird responses that you had after treatment. Drugs like methamphetamine can have a profound effect on the neurological and circulatory system. I would assume that it was the meth.
Kind regards,
Jeff
Peter Bonadonna says
Short runs of VT are not unusual and can happen in patients without stimulant drugs on board. The physiology is that when the SVT overdrives the other pacers, their inherent rates elevate. When you give adenosine it only depresses the atrial SA and AV nodes. You and see almost any arrhythmia for a short bit. Take your pulse and it will be all better by the time you are done.
sijo sebastian says
why we are giving adenosine 6/12mg in stable wide regular tachycardia?what is the rational?
thank u
Jeff with admin. says
AHA states:
AHA usually adjusts their guidelines when clinical data supports that something is effective. In this case adenosine has proved to be effective for both diagnosis and treatment.
Kind regards,
Jeff
allen says
aha says consider adenosine for the stable patient, only once as a diagnosis tool only …not for treatment of vt. it may slow the rhythm of a brief peroid to find underlying rhythms (have your monitor printing during this time). if there is a noted change and the patient remains stable call an expert. if there’s no changes and the patient is still stable go to amiodarone. i.e. stable .. vagal … rx… expert.
Teri says
For wide complex tachycardia, it states to “consider adenosine.” The rational is that it could be a SVT with aberrancy such as a Bundle Branch Block. In that case adenosine is treating the rate. The other thing to remember is that ALL stable tachycardias need a 12 lead. A 12 Lead can give us more information than the naked eye, such as a PR Interval on something that looks like a VT. – Teri
Marek says
During the recent angiogram ADENOSINE was used on me, which I was not aware of.
Next ten days I experienced sewere angina attacks up to 7 a day. I could not do simple home duties or walk even 50 m. It was agony. My GP sugested ADENOSINE as the reason. Can you please comment on that.
Kind regards,
Marek.
Jeff with admin. says
The half-life of adenosine after injection in to the body is 10 seconds. This means that the body would completely metabolize the drug in less than 60 seconds. There would not be any adensoine left in your system within a very short time. I don’t see how the adenosine could have been the cause of your ongoing symptoms after the angiogram.
Kind regards,
Jeff
Hollie says
I find this interesting as i have a condition called wolffs parkinsons white syndrome, which causes SVT ,and have many admissions to A&E in the past, adenosine was also used in me and caused extreme pain in my body and chest it was awful, and it never worked, eventually they started administering IV flecinide slowly through a bump and was the only thing that worked went i was admitted,
Andrea says
Can adenosine cause cardiac arrest?
Jeff with admin. says
Yes, adenosine can cause cardiac arrest. If it does, use ACLS protocol to treat the cardiac arrest.
Kind regards,
Jeff
Jeff with admin. says
This can be a difficult thing. Here is one tip. If the patient has not been in cardiac arrest for any significant length of time, if you see something that looks like fine VF it probably is. It take a dying person a while to finally achieve asystole.
If in doubt and you think the pt. is in VF, shock the pt. according to the left branch of the cardiac arrest algorithm.
Kind regards,
Jeff
Crystal says
I have an allergist he suggested though I react very badly have anaphylaxis not to list the cardiac meds. I had the same meds you spoke about i believe the max dosages of 6. Then they tried other heart medications. It wasn’t painful for me I have a zero pain tolerance so what the heck happened in your procedures. i stood up went to the bathroom thought I was going home not the icu the meds didnt work on svt except for maybe ten minutes. I was transferred for emergency ablation but they decided to not do the pacemaker so I dread that day.
Jacqui says
Approximately 1-2 times per year, I experience tachycardia. Typically, my heart rate will climb to around 160 bpm, which in itself isn’t that bad but it also feels like it’s not beating normally. My heart rate will climb above this when exercising and I won’t notice anything. It can last for over 8 hours if I do nothing, and can go back to normal as suddenly as it started.
Anyway, for the most part I have learned that I can make my heart go back to normal by holding my breath for as long as possible (till I almost lose consciousness). Sometimes though, I have to go hospital. I have been cardio verted once before (they had to shock me twice but that did fix it) but every time they want to try adenosine. I hate this drug for several reasons. First and foremost, it seems to have absolutely no effect whatsoever on my heart, I’ve had it 4 times and it’s never done anything to slow my heart rate or make it feel normal again. What it does do it is cause extreme pain, in my limbs and if the dose is high enough, up the back of my neck. 6ml is bad but tolerable, 18ml is absolute agony. It only lasts for 5-10 seconds and happens within 1-2 seconds of it being injected. Afterwards I feel fine, except of course for my heart which hasn’t changed.
Doctors don’t believe me when I tell them this drug has no effect on my heart until they see it, and since it’s always in emergency, they don’t have time to get my past records and they just want to try it again. I was really hoping to find some insight and see what it means to have this side effect.
Jacqui says
Maybe I should add, I have had an ep study done but they were unable to induce the arrhythmia on the table and they could not find anything wrong. No external pathways and no triggers. All ECG’s seem to show a normal but fast rhythm. I can feel the instant my heart goes back to normal, even if my heart rate does not change. From that point onwards, slow breathing will reduce my heart rate, whereas before, lying down, slow breathing etc have no effect and I feel like I can run and function normally, whereas when it feels strange I feel short of breath and light headed.
Jeff with admin. says
Hi Jackie,
Thank you for your question regarding adenosine.
Your story is very interesting and I have never heard of anyone having the side effect that you have. I can say that it is most likely related to the effects of adenosine on the central nervous system. Adenosine can have significant effects on receptor sites in central nervous system.
The reason why this only lasts for a few seconds is because adenosine is rapidly metabolized and neutralized in our bodies.
In the future, I would be more insistent with the physicians who are attempting to give you adenosine. Maybe you should keep a copy of your medical records with you so that you can always be ready to share this information with them.
Kind regards,
Jeff
MarciaAndersen says
I would list adenosine as an allergy if I were you Jacqui. They can’t argue with that
Bill Raydor says
You don’t need to add it as an allergy – JUST REFUSE! When you are in the rhythm, it is not life-threatening by itself and you are of sound mind – so REFUSE! Say NO! YOU CAN NOT INJECT THAT SUBSTANCE IN TO MY VEIN! This will force them to try other drugs or electricity.
Jason says
I have a history of SVT and when I’ve gone to the ER w/ a heart rate > 200 bpm the MD ordered cardizem instead of adenosine. Maybe this is something that you can look into
Jeff with admin. says
Cardizem can be used for certain situations when tachycardia is present. Cardizem is a calcium channel blocker and will slow the conduction of electricity through the heart thus slowing down the heart rate. The cause of the rapid heart rate will influence the decision about what medication should be used.
Kind regards,
Jeff