Add Adenosine to the Flush

You have a patient in SVT, failed vagal maneuvers. Time to treat with adenosine. 

You all know this cute little three-way stop cock. Seems simple enough. That is until you need to use it... the stop and go seems somehow far more confusing than it really is.

And the one time you MUST know how to use it is to rapidly administer adenosine. You need access in the antecubital or proximal upper extremity.

Why the rush? Adenosine is rapidly metabolized by erythrocytes and vascular endothelial cells - so with its 10 second half-life, we have to administer and flush it quickly so it can reach the heart. 

Surely, there has to be an easier way! Well, folks. There is!

Make sure you have your ECG rhythm strip running, zoll pads on the patient, and explain the patient that this might "feel funny"  (as their heart stops for just a wee bit). 

• Grab a 20-mL (or 30-mL) syringe.

• Desired dose of Adenosine (6 mg or 12 mg)

• Draw up the adenosine AND the normal saline in the same 20-mL syringe.

• Administer via fast IV push

That's it! 

Adenosine is safe and maintains its effectiveness mixed with normal saline. One study even used OI access for conversion of SVT in an infant. 

Only have central access (hemodialysis port, central line)??? Per 2010 ACLS guidelines drop the dosing: 

• 1st dose: 3 mg (instead of 6)

• 2nd/3rd doses: 6 mg (instead of 12)

This lower dosing minimized risks of prolonged bradycardia. ALSO - use this lower dosing if the patient is taking dipyridamole or carbamazepine as these two medications potentiate the effects of adenosine.

REFERENCES:

J Korean Soc Emerg Med. 2003 Aug;14(3):224-227 

https://www.resus.com.au/2015/03/26/a-new-way-to-give-adenosine-in-svt/

https://www.aliem.com/2012/12/trick-of-trade-combine-adenosine-and/
Weberding NT, et al. Adenosine Administration With Stopcock Technique Delivers Lower-Than-Intended Drug Doses. Ann Emerg Med 2018;71(2):220-4.

https://acls-algorithms.com/acls-drugs/acls-and-adenosine/comment-page-2/

Intranasal Analgesia and Anxiolysis

Today we will be discussing IN anxiolysis and analgesia, especially useful in our pediatric population.  An appendix with a BAN administration outline is also attached. Indications

Perfect for kids coming in with acute trauma (laceration, need for x-rays, etc) or patients undergoing procedures such as I&D of an abscess.

May be used prior to obtaining x-rays for pain control in children not necessarily needing a line for reduction (or even in those needing a line as this may be a faster way to reduce pain, and may help provider in obtaining IV line).

Routine Medications – Analgesia/Anxiolysis Dose

• Analgesia: Fentanyl (1-1.5mcg/kg), Ketamine (0.5mg/kg)

• Anxiolysis: Midazolam (0.2mg/kg)

Other IN Medications: Midazolam, Precedex (dexmedotomidine), flumazenil, naloxone

Pearls of Administration

Have patients blow their nose first if possible.

Try to limit dose to 0.3mL per nostril (certainly no more than 1 mL per nostril), using concentrated solutions. 

Divide larger volumes over two nostrils.

May deliver in aliquots 10-15 minutes apart if larger.

Remember, it’s a good idea to put patients on a pulse ox prior to administration.

Account for “dead space” of atomizer (~1mL).  

APPENDIX

BAN Dosing

Remember, there is also the BAN (breath actuated nebulizer) for medication administration which is a an alternative to intranasal medications when tolerated.  Only use BAN in Breath Actuated Mode in ED.

Here is the dosing for BAN:

• Fentanyl:

  • Adults: 4mcg/kg dose titrated q 10 min up to three doses

  • Pediatrics: 2-4 mcg/kg titrated q 10 min up to three doses

• Morphine:

  • Adults: 10-20 mg titrate q 10-15 min up to three doses

  • Pediatrics: 0.2 mg/kg q15 min up to three doses