Cardizem Vs. Adenosine in SVT

[Rialaigh]

To preface I did to a forum search and then a google search and was not satisfied with the answers I found there.

As the title states.

What I was told by an EM Dr. is that he would always prefer to give Cardizem SIVP for SVT over Adenosine as long as the patients BP is stable, and by stable he was saying anything over 90 systolic for most patients. He says Adenosine in his experience causes more problems and is just flat out more uncomfortable for the patient and he has had good experience with Cardizem.

There must be more to this...if Cardizem could be used for most SVT in stable patients with much much more comfort than why is Adenosine so prevalent within the EMS and Emergency Room communities.



This stemmed from
a patient that came into the ER.

Female in her 60's, HR 220-230 SVT, BP 110/70ish (don't remember exactly). Pain a 4/10 more "discomfort". Pack a day smoker but satting 95%+ on room air. History of SVT X 3 times, last one was several months ago, PT has never seen a cardiologist

Doc said grab an IV and away we went with Cardizem right after we got her vitals and a line. He didn't even flinch or think about Adenosine. 5 minutes after the first dose of Cardizem she converted to normal sinus rhythm, we kept her for an hour in the ED and let her go home. No problems, everything else stayed completely stable. She said the last time she was in the ED she was given Adenosine and it took 3 pushes to get her to convert and hurt like hell (I know it hurts like hell)


Anyways, whats the dealio people ?

 

[46Young]

Did the MD have the benefit of labs before going with Cardizem?

Also, in pre-hospital EMS, the educational levels vary greatly. Perhaps the reduced contractility that comes with Cardizem was deemed too great of a risk. If you negatively affect contractility, you may need to push CaCl, and all of this is being done with no labs. Or, you may drop their BP, then have the need to cardiovert them, which is most definitely more painful then the Cx discomfort experienced with Adenosine.

It's not always the best to play games without the benefit of blood work. It's like an aggressive medic wanting to push Bicarb on the pt in DKA or the hypermetabolic, altered drug abuser.

Edit: using a 16G in the AC definitely helps with our success rate when using Adenosine.

 

[Smash]

Calcium channel blockers (we use verapamil) and adenosine are equally effective in reverting AVNRT. Calcium channel blockers have a greater side effect profile (primarily hypotension). Adenosine is generally "safer" but it does make the patient feel appalling. If the patient has had adenosine before and it took 3 doses then it seems absolutely humane to give her something a bit kinder and equally effective given that her BP should tolerate any drops. The other option would be a little dose of benzo before hand, but I'd probably go with calcium channel blocker as well.

 

[VFlutter]

Anectodal experience: I have only seen Adenosine used a handful of times in the hospital, almost exclusively in the ER or cath lab. We almost always use cardizem for any tachyarrythmia from A fib to SVT. Most patients convert fairly quickly with a bolus and drip. Some patients can get pretty hypotensive with it. Besides that I do not see much reason to pick adenosine.

 

[systemet]

The conversion rate for SVT with adenosine is pretty high, but there are some concerns about its use in pt.s with a hx of asthma or COPD, or on certain meds, e.g. carbmazepine.

Fortunately the duration of action is pretty short, limiting the severity of most of the effects- although there are case reports of some pretty horrible status asthmaticus.

Personally I like the drug.

 

[ExpatMedic0]

Edit: using a 16G in the AC definitely helps with our success rate when using Adenosine.

I have done it successfully on the first dose of 6 in a hand vein with a 22G. What do I win?

 

[medicsb]

I've never had 6 of adenosine not work. I suppose a potential benefit of CCB (or even a beta blocker) would prevention of recurrence of AVNRT, but that's be short lived if not followed by an infusion or PO dosing. Before adenosine become common practice, verapamil or levophed were used.

 

[Christopher]

To preface I did to a forum search and then a google search and was not satisfied with the answers I found there.

As the title states.

What I was told by an EM Dr. is that he would always prefer to give Cardizem SIVP for SVT over Adenosine as long as the patients BP is stable, and by stable he was saying anything over 90 systolic for most patients. He says Adenosine in his experience causes more problems and is just flat out more uncomfortable for the patient and he has had good experience with Cardizem.

There must be more to this...if Cardizem could be used for most SVT in stable patients with much much more comfort than why is Adenosine so prevalent within the EMS and Emergency Room communities.

Adenosine is prevalent because the more common regular narrow complex tachyarrhythmias are reentrant rhythms. Adenosine has a pretty narrow side effect profile for the termination of suspected reentrant NCT.

Cardizem has a huge side effect profile when compared to adenosine, especially for simply reentrant rhythms.

I'm not sure where your MD got that experience that diltiazem was somehow less likely to cause an adverse effect, but perhaps they're one of the few that gives dilt really slow. I do sympathize with the notion that adenosine is extremely unnerving for patients.

This stemmed from a patient that came into the ER. Female in her 60's, HR 220-230 SVT, BP 110/70ish (don't remember exactly). Pain a 4/10 more "discomfort". Pack a day smoker but satting 95%+ on room air. History of SVT X 3 times, last one was several months ago, PT has never seen a cardiologist.

Doc said grab an IV and away we went with Cardizem right after we got her vitals and a line. He didn't even flinch or think about Adenosine. 5 minutes after the first dose of Cardizem she converted to normal sinus rhythm, we kept her for an hour in the ED and let her go home. No problems, everything else stayed completely stable. She said the last time she was in the ED she was given Adenosine and it took 3 pushes to get her to convert and hurt like hell (I know it hurts like hell)

Anyways, whats the dealio people ?

SVT at 220-230 is getting pretty quick for my liking to give a CCB to. Perhaps they should just start with 18mg or 24mg of adenosine for her and be done with it.

Long and short of it is if you suspect a reentrant rhythm, adenosine is the better choice. If you suspect an automatic rhythm, a CCB or B-blocker is the better choice.

 

[Veneficus]

Oh yea?

My doctor can beat up your doctor...

I'm not sure where your MD got that experience that diltiazem was somehow less likely to cause an adverse effect, but perhaps they're one of the few that gives dilt really slow. I do sympathize with the notion that adenosine is extremely unnerving for patients.

I wish I had $1 for every doctor that experience a n=1 bad outcome and stopped using said intervention thinkiing that was normal or even likely.

Having said that though, sometimes the side effect or perception of the treatment of a given med is beneficial over the statistical "X drug is indicated for Y condition" for various patients.

Some of it is personal preference. (doctors get to do that)

An example of the former is caugh caused by ACE inhibitors. Sure it may control the BP really well, but the undesired effect is greater than the unappreciated BP reduction for some patients. "suffer with it, it is good for you" is not the proper response.

In the later, here are a few of my personal choices:

I like promethazine over diphenhydramine and second generation H blockers. Mostly because of the sedation effect. Is it the best drug for a given condtion? I guess it depends on what you consider the best. (people getting it for nausea why anxiously waiting in the hospital don't seem to mind the sedative effect either and then I don't have to give them a banzo on top of it.)

I like dual ab therapy over single. (amox w/clav with azith in particular.) I probably should get some stock in those companies. (don't worry, I can't afford stock, so it won't present an ethical issue)

I love bupivicaine over lidocaine. In my mind it is not even a choice. It lasts longer, usually well after the pt goes home, has a better biochem and pharm profile, makes people happy. That makes me happy.

I also really like silk suture. It is just more pleasant to work with than the synthetics.

Are these things "better?" I think it is just a different way. I don't get very many complaints.

SVT at 220-230 is getting pretty quick for my liking to give a CCB to. Perhaps they should just start with 18mg or 24mg of adenosine for her and be done with it.

It is a comfort zone thing. When there are lots of staff and tools, you can push the limits a little more.

Perfect example is permissive hypotension. It actually makes me laugh when I see 90 or 100 systolic as a goal.

Long and short of it is if you suspect a reentrant rhythm, adenosine is the better choice. If you suspect an automatic rhythm, a CCB or B-blocker is the better choice.

Better is subjective.

 

[Christopher]

Oh yea?

My doctor can beat up your doctor...

Probably. The only MD I see is a pulmonologist (PA referral)...who I recently saw in our trauma room botch 3 A-lines before asking for help, so perhaps I should find a new pulmonologist.

I wish I had $1 for every doctor that experience a n=1 bad outcome and stopped using said intervention thinking that was normal or even likely.

Having said that though, sometimes the side effect or perception of the treatment of a given med is beneficial over the statistical "X drug is indicated for Y condition" for various patients.

Some of it is personal preference. (doctors get to do that)

EMS in my area is no different, it seems to be most prevalent with narcotics and benzo's. We've got a pretty wide latitude in Rx choices for many complaints (I have 3 antiarrhythmics for WCT and 3 for NCT), so we too get to benefit/suffer from personal preference; so yeah, providers tend to stick within their comfort zone.

In the later, here are a few of my personal choices:

...<snip>...

Are these things "better?" I think it is just a different way. I don't get very many complaints.

I think all of these are reasonable choices between treatments. Sometimes you have reasonable choices between treatments, other times it is a little more cut and dry.

It is a comfort zone thing. When there are lots of staff and tools, you can push the limits a little more.

Re: CCB's to patients taching above 220...I view this as The House Always Wins sort of thing. At some point you're going to lose the bet that you won't hit the side effect profile (or won't hit it that hard).

Better is subjective.

I think in the case of CCB's for NCT, the phrase "better" has some objective criteria around it.

 

[Sublime]

Anectodal experience: I have only seen Adenosine used a handful of times in the hospital, almost exclusively in the ER or cath lab. We almost always use cardizem for any tachyarrythmia from A fib to SVT. Most patients convert fairly quickly with a bolus and drip. Some patients can get pretty hypotensive with it. Besides that I do not see much reason to pick adenosine.

On another note the ED I worked in we grabbed adenosine every time and it never failed. Some docs preferred to skip the 6mg dose and jump straight to 12 every time.

Besides the pain from having to push it really hard and the bad feeling the patient gets from that short conduction pause.. I have never seen any ill side effects and don't see a reason to not use it over cardizem.

 

[Rialaigh]

have any of you had issues with heart pauses that...don't restart..with adeonsine. I know its standard procedure to have the crash cart right next to the patient when pushing adenosine. I am not sure how prevalent it is for the patient to require a shock after pushing adenosine. I would think this would be considered a fairly detrimental side effect if it happens even infrequently.

 

[Sublime]

have any of you had issues with heart pauses that...don't restart..with adeonsine. I know its standard procedure to have the crash cart right next to the patient when pushing adenosine. I am not sure how prevalent it is for the patient to require a shock after pushing adenosine. I would think this would be considered a fairly detrimental side effect if it happens even infrequently.

Never heard of it ''not restarting''. Adenosine has an extremely short half life, so it's not uncommon for the opposite to happen and it not have an affect at all. That's why it's recommended to be pushed through the AC or higher.

Also, if the patient remained asystolic after an adenosine push, a shock is not going to help. You don't shock asystole

 

[medicsb]

have any of you had issues with heart pauses that...don't restart..with adeonsine. I know its standard procedure to have the crash cart right next to the patient when pushing adenosine. I am not sure how prevalent it is for the patient to require a shock after pushing adenosine. I would think this would be considered a fairly detrimental side effect if it happens even infrequently.

Is the crash cart their because of the adenosine or is it there because the patient is experiencing an arrhythmia?

I believe there are a number of case reports about prolonged asystole from adenosine necessitating CPR, but I doubt it is anywhere near a common occurrence. It is also not unheard of for patient to go in to v-fib in cases of accessory pathway conduction.

There have been studies on the prehospital use of adenosine. After a very cursory review, I didn't see an mention of cardiac arrest s/p adenosine. Feel free to do a more exhaustive search: www.pubmed.com

 

[Veneficus]

I believe there are a number of case reports about prolonged asystole from adenosine necessitating CPR, but I doubt it is anywhere near a common occurrence. It is also not unheard of for patient to go in to v-fib in cases of accessory pathway conduction.

There have been studies on the prehospital use of adenosine. After a very cursory review, I didn't see an mention of cardiac arrest s/p adenosine. Feel free to do a more exhaustive search: www.pubmed.com

While this is more than reasonable, I have never even heard of anyone or anyone's cousin's sister's uncle's grandfather who have actually seen this.

Usually if something goes wrong I at least hear about it.

 

[Rialaigh]

So, given the option of adenosine or cardizem in a patient with SVT that is seemingly stable SVT 180-220, BP 110/75, o2% is fine and PT looks okay, what do you go with with on the rig? does transport time factor into your decision? Does your decision change in the ER setting?

 

[Veneficus]

So, given the option of adenosine or cardizem in a patient with SVT that is seemingly stable SVT 180-220, BP 110/75, o2% is fine and PT looks okay, what do you go with with on the rig? does transport time factor into your decision? Does your decision change in the ER setting?

I think my decision would be based on whether that person was likely to be admitted for more than 12 hours or not.

If I expected a short turnaround, probably adenosine.

If I expected them to be a overnight or longer guest, probably cardizem.

 

[Rialaigh]

I think my decision would be based on whether that person was likely to be admitted for more than 12 hours or not.

If I expected a short turnaround, probably adenosine.

If I expected them to be a overnight or longer guest, probably cardizem.

So basically overall health of the patient with a focus on cardiac and pulmonary condition?

 

[46Young]

I have done it successfully on the first dose of 6 in a hand vein with a 22G. What do I win?

Did you chase it with a pressure bag or something? That's pretty impressive!

You win a cookie

J/K

 

[Veneficus]

So basically overall health of the patient with a focus on cardiac and pulmonary condition?

Basically that or age.