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SVT Adenosine vs Calcium Channel Blocker

Justin Morgenstern, MD and Anand Swaminathan, MD FAAEM
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12:59
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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03:40

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EMRAP 2018 07 July Vol.18 V2 Written Summary 390 KB - PDF

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Steve D. -

What is your plan if a calcium channel blocker does not work? Adenosine? Electricity?

Justin M., M.D. -

If the calcium channel blocker wasn't working, my first thought would be: is this really SVT? Calcium channel blockers are incredibly effective for re-entrant tachycardias (98% in the Lim paper), so I would be surprised it wasn't working. I have been using calcium channel blockers as first line for 7 years now, and haven't encountered a patient that didn't convert.

Next, I would probably give more calcium channel blocker. That seems like a silly answer, but unless the patient is becoming hypertensive, has some other contra-indication, or I have already given incredibly high doses, I would probably just give more.

If that didn't work, and I had to move on to plan b, I agree with Swami. I would discuss the options with the patient and let them decide. My preference would probably be electricity at that point, because it is weird to be refractory to calcium channel blockers, and I might expect them to be refractory to adenosine as well. If they do want adenosine, I give them sedation.

Anand S., M.D. -

Can't speak for Justin on this but if CCB doesn't work, I will consider adenosine or electricity depending on patient preference.

Kevin M., MD -

It's hard for me to justify the extra time, use of ED resources and most importantly nurse monitoring that seems to be needed for treatment with CCB's.

Anand S., M.D. -

Kevin - I actually find that less monitoring etc needed. Adenosine invariably ends up with lots of monitoring and folks gathered around since the heart is actually stopping. CCB, on the other hand, simply needs the patient to be on the monitor. Continuous EKG is nice but not necessary. In my experience, it ends up taking the same amount of time to break someone with CCB as it does with adenosine (not talking about just time from drug in to breaking but the total time)

Justin M., M.D. -

It probably will depend a lot on where you work. I know there are a lot of hospitals with fairly ridiculous protocols for how certain medications must be given. But in my hands, the use of a calcium channel blocker is significantly less resource intensive. With adenosine, there are always multiple people around the bedside - it sort of looks a bit like a real resuscitation. And they are often needed, because the rapid push of adenosine can be technically difficult (needs multiple hands). With a calcium channel blocker, I put the patient on a monitor, set the blood pressure to cycle, hang the drug in a minibag, and then just walk away to see another patient or catch up on charting. When I come back in 5 or 10 minutes, the patient has almost always converted.

paul f. -

I warn patients about the chest pain and go with adenosine. I haven't seen many patients complain much about the pain, and in any case lasts a few seconds. CCB and adenosine are equally effective. Both very safe but if have hypotension more likely to occur with CCB. Also adenosine is easier in our ED

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EM:RAP 2018 July Full episode audio for MD edition 229:23 min - 319 MB - M4AEM:RAP 2018 July German Edition Deutsche 120:44 min - 166 MB - MP3EM:RAP 2018 July Spanish Edition Español 90:31 min - 124 MB - MP3EM:RAP 2018 July Australian Edition Australian 35:17 min - 48 MB - MP3EM:RAP 2018 July Canadian Edition Canadian 24:10 min - 33 MB - MP3EM:RAP 2018 July French Edition Français 27:05 min - 37 MB - MP3EM:RAP 2018 07 July Individual MP3 Files 293 MB - ZIPEMRAP 2018 07 July Individual Summaries 742 KB - ZIPEMRAP 2018 07 July Spanish Summary 1 MB - PDFEMRAP Board Review Answers 2018 07 July Vol.18 07 116 KB - PDFEMRAP 2018 07 July Vol.18 V2 Written Summary 390 KB - PDFEMRAP Board Review Questions 2018 07 July Vol.18 07 407 KB - PDF

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