Adenosine induced VT?

[celticcare]

Hi guys and gals, ok so this is a spin of the thread that I started in the Equipment section in regards to synchronised cardioversion and defibrillation settings.

Patient presents with SVT, textbook narrow regular complex rate of 210-223. Pt GCS 15/15, BP holding in a normotensive state and complaining of Chest pain secondary to the Tachycardia. The patient is a 43 year old male, normally fit and well, has a history of Parasoximal AF which has needed cardioverting 5 times within the last 5 years. Decision made by Attending to take patient into the resuscitation area and give an adenosine push to hopefully chemically cardiovert the patient. 6mg of Adenosine was given first and there was a slowing of the rate with what looked like a flutter pattern on the screen when the patient then went into Ventricular Tachycardia. 150 mg of Amioderone IV push was given with no success. Decision made for patient to be sedated and 100 joule sync shock given. As soon as the shock was given, patient went into Vfib and 360 joule defib given *first defib I'd done in a while so put the full joules through * Patient reverted to sinus rhythm post shock and remained in it and no return of SVT or VT *or thankfully as well VF*.

My question, is that has anyone had similar episodes after giving adenosine with the rhythm changing to a VT post push. Its surprised me as I have never seen it. I will update tomorrow on any further details on any outcome from further investigation.

Scotty

[Doczilla]

This can happen with a preexcitation syndrome like WPW and underlying a-fib. It's not v-tach per se, but conduction of atrial impulses throughout the accessory pathway (Kent bundle). Since they depolarize the ventricle more slowly than if the impulses came down through the His purkinje system, it appears wide complex.

'zilla

[Carl Ashman]

You state that the pt. has a Hx of A-fib. As far I know, adenosine is contraindicated in A-fib for this very reason. Was a 12-lead done prior to administration?

Carl.

[Doczilla]

You state that the pt. has a Hx of A-fib. As far I know, adenosine is contraindicated in A-fib for this very reason. Was a 12-lead done prior to administration?

With a rate of 210-220, that would be pretty hard to pick up, even on a 12 lead.

'zilla

[celticcare]

With a rate of 210-220, that would be pretty hard to pick up, even on a 12 lead.

'zilla

12 Lead was done showing a regular rhythm of over 220 beats per minute, once rosc was achieved patient was in Sinus rhythm with occasional pvc's.

[bizar.one]

definately hard to pick up on a 3-lead or 12 lead ECG with a rate that fast... i guess the only thing i can think of that would definately give it away would be the QRS complex to be a regular pattern... if this does not seem to be regular then you are maybe dealing with an accelerated a-fib rhythm therefore the pt. would be more likely in need of a calcium channel blocker.. in most cases especially if pt does have a history of A- fib i would have probably initiated care with maybe a 500 cc bolus followed by sedation and then sunchronized cardioversion just for this matter. Initially adenosine is a drug that is used to yes decelerate the heart but mostly to treat the underlying rhythm found. hope this helps....

[Katiebug]

I had a patient with what I thought was SVT on one occasion. En route to the ED I pushed adenosine twice. 6 & 12. Both times there was absolutely no change on the monitor.

I told the attending at the hospital what I had done. He said when that happens, it's usually an underlying rhythm of a fib. He pushed cardizem and fixed it.

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[Emtpbill]

I was always of the thinking that adenosine is kind of a diagnostic drug. Yes it can chemically cardiovert, but more importantly allow you to see the underlying rhythm of what is causing the extreme rate by slowing the rate long enough and take steps from there.

[scratrat]

You state that the pt. has a Hx of A-fib. As far I know, adenosine is contraindicated in A-fib for this very reason. Was a 12-lead done prior to administration?

Carl.

I don't remember hearing that it is contraindicated with atrial fib. It is contraindicated in SSS and high degree blocks, which I never understood anyway since a 3rd degree heart block is not going to be at a rate of 200 bpm. Or at least it is highly unlikely anyway.

I can remember giving it to someone with no known history whatsoever only to find that when the rhythm breaks, you can see obvious A-fib. When it returns to SVT (or more appropriately A-Fib with RVR) then the doctor ordered Cardizem.

Doczilla said where I was going with it - I have heard of that with WPW and SSS. I could have sworn adenosine was contraindicated for WPW as well, but I can't recall exactly on that one.

[Tom B.]

I could have sworn adenosine was contraindicated for WPW as well, but I can't recall exactly on that one.

Specifically AF/WPW where adenosine (along with CCBs) can induce VF. When you give adenosine it's a good idea to place the combo-pads first.