2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary
J Am Coll Cardiol. 2014;64(21):2246-2280 Free full text
Two cases of failed cardioversion of SVT after tibial intraosseous administration of adenosine in infants are described in this month’s Pediatric Emergency Care. Both cases were subsequently cardioverted by intravenous adenosine. The maximum intraosseous dose given was 0.25 mg/kg. The successful IV doses were not higher than the IO doses.
It has been noted before that infants may require relatively higher doses of adenosine than children and that 0.2 mg/kg might even be considered a starting dose in infancy. I wonder if a bigger IO dose would have been effective, or whether a proximal humeral insertion site would make a difference. IO adenosine has been successfully used in infants and piglets.
This interesting case series provides a helpful caution in the management of paediatric SVT.
ABSTRACT: Supraventricular tachycardia (SVT) is a common tachyarrhythmia in the pediatric population that can necessitate immediate treatment. Adenosine has been well studied as a mainstay treatment, but the methods of adenosine administration have not been very well delineated. The intraosseous technique has presented itself as a possible method of administration. We describe 2 cases in which adenosine was administered through bone marrow infusion to convert SVT without success. The cases we describe show that intraosseous is not a reliable method of administering adenosine to stop SVT. Both patients presented with SVT refractory to vagal maneuvers and difficult intravenous placement. Intraosseous access was achieved, but administration of adenosine at increasing doses was unable to successfully convert the arrhythmia.
Intraosseous Infusion Is Unreliable for Adenosine Delivery in the Treatment of Supraventricular Tachycardia
Pediatr Emerg Care. 2012 Jan;28(1):47-8
The Ottawa Aggressive Protocol is used to treat recent onset (< 48 hours) atrial fibrillation or flutter with procainamide and/or cardioversion to allow discharge from the emergency department.
A cohort of 660 patient visits is described in a paper in the Canadian Journal of Emergency Medicine, 95.2% involving atrial fibrillation and 4.9% involving atrial flutter. The mean age of patients enrolled was 64.5 years. In total, 96.8% were discharged home and, of those, 93.3% were in sinus rhythm. All patients were initially administered intravenous procainamide, with a 58.3% conversion rate. A total of 243 patients underwent subsequent electrical cardioversion with a 91.7% success rate. Adverse events occurred in 7.6% of cases: hypotension 6.7%, bradycardia 0.3% and 7-day relapse 8.6%. There were no cases of torsades de pointes, stroke or death. The median lengths of stay in the ED were as follows: 4.9 hours overall, 3.9 hours for those undergoing conversion with procainamide and 6.5 hours for those requiring electrical conversion.
This proactive approach by emergency physicians seems excellent for patients who in some centres probably still get admitted for this presentation. I’m not sure why they continue to use a drug with a conversion percentage in the 50’s, which the authors have demonstrated before. Many of us routinely use flecainide for recent onset AF in patients likely to have structurally normal hearts, as it has been shown to be superior to procainamide in AF.
Association of the Ottawa Aggressive Protocol with rapid discharge of emergency department patients with recent-onset atrial fibrillation or flutter
Canadian Journal of Emergency Medicine 12.3 (May 2010): p181(11)
Based on a study of 453 consecutive patients undergoing their first transthoracic electrical cardioversion for atrial tachyarrhythmias, recommendations were developed to aim at delivering the lowest possible total cumulative energy with ≤2 consecutive shocks using the specific truncated exponential biphasic waveform incorporated in Medtronic Physio-Control devices: they recommend an initial energy setting of 50 J in patients with atrial flutter or atrial tachycardia, of 100 J in patients with atrial fibrillation (AF) of 2 or less days in duration, and of 150 J with AF of more than 2 days in duration. If the initial shock fails to restore sinus rhythm, a rescue shock of 250 J for AFL/AT or of 360 J for AF should be applied to secure the highest possible probability of successful cardioversion for each patient.
Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks
Am J Emerg Med. 2010 Feb;28(2):159-65