Everybody in the FOAM world probably has already seen these two ideas, but I wanted a spot here to be able to find them on my own site so, SVT…
Revert-Style Vagal Maneuver
Have patient exhale into a 10ml Syringe with a force sufficient to move the plunger for 15 seconds followed by placing the patient supine and holding up their legs for 15 seconds (Lancet 2015;386(10005):1747). They repeated the maneuver x 1 if not initially successful. They more than doubled the success rate of the vagal maneuver using this addition.
- See the excellent RebelEM Post for more info
I've tried the REVERT technique twice now, both times with success–how do you like that for evidence?
Adenosine without the Annoyance of the 3-Way Stopcock
Bryan Hayes, an extraordinary ED Pharmacist, taught me how to get rid of the stopcock ridiculousness when administering adenosine. Just draw the adenosine into a 20 ml syringe filled with saline. Then just rapidly push that bad boy. So simple, so smart!
Now as to whether you should be giving adenosine, given the patient's misery at the induction of death (albeit just for a few seconds), is an entirely different question.
Scott Weingart
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Great minds…
http://broomedocs.com/2015/12/clinical-case-123-svt-better/
Any thoughts on verapamil if REVERT fails Scott?
Casey
Not a big fan of verapamil, compared to real agents like diltiazem. Time for your country to get that drug and nicardipine. Is there a big calcium channel blocker cabal–seriously what’s the deal. Have started to go to CCBs rather than adenosine when it seems that near death may freak out my patient.
Pharmalag…. Slightly slower than knowledge translation ?
Maybe this can help:
Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009.
http://www.ncbi.nlm.nih.gov/pubmed/19261367
“The conversion rates for the calcium channel blockers (98%) were statistically higher than the adenosine group (86.5%), p=0.002, RR 1.13, 95% CI 1.04-1.23. The initial mean change in blood pressure post-conversion in the calcium channel blocker group was -13.0/-8.1 mmHg (verapamil) and -7.0/-9.4 mmHg (diltiazem) and 2.6/-1.7 mmHg for adenosine.”
Great post, Scott. Thanks!
Cheers,
HL
We use two port IV tubing and always have it going into the antecubital fossa. The adenosine syringe gets hooked up to the most proximal port and a large saline flush hooked up to the port distal to that. When it’s go time, the adenosine is pushed, followed by a quick flush of the saline. This way, there’s no switching of syringes or changing of stopcocks
why would you still do that after finding that adenosine has no diminished effect when mixed with the flush?
It’s just easier for us to grab a prefilled adenosine and saline syringe and fire them both in then it would be to reconstitute the adenosine into 20mL of saline. Thanks for posting the new vagal maneuver video!
Ok, I think I am not getting across the the technique. You don’t need to reconstitute anything. Take the prefilled syringe of adeonsine, attach a needle to it and inject it into the 20 ml syringe where you’ve pulled the plunger down to make some space.
Just like some poster’s above, I/we have never used the stop cock method in the field (EMS) in our local agency. We have used a “two syringe”, two port technique. In fact about the only time we routinely use stop cocks is on IO’s or drawing up ped meds.
Distal port (closest to the patient) has the 10 ml syringe with the Adenosine, the next port has a 20 ml syringe with saline. Line above the 20 ml syringe is pinched manually.
On a three count. (1) push adenocard (2) push 20 cc (3) unkink line and run wide open for 100 cc or so.
Seems to work well with 2 providers, especially at 3AM (on a 24 or 36 hour shift) when brains are functioning at 2/3rd capacity.
That said, this new information seems to warrant reconsideration.
Steve
Hello!
1) Love your podcasts, blog, and the merger with pulmcrit blog
2) Is there a standard period of observation after administration and successful conversion to sinus rhythm after using adenosine for PSVT?
Thanks!
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