PIG-EMS: aDEVILsine – REVERT, Valsalva, and Not Giving Tornados In The Chest

pSVT is a fairly common presentation for tachycardia and a common 911 complaint. I get about 1-2 a year, and I always try the Valsalva maneuver, and it fails most of the time.

But that’s okay! We start a line and bust out… the ADENOSINE!!! Probably the coolest drug in the bag, the one that lets us tell our friends and family “Yeah… I stop hearts for a living, and get them started again.” We feel like badasses, there’s the thrill of watching that transient asystole…

…But what about the patient?

Ain’t Nobody Likes (Getting) Adenosine

Does adenosine WORK? OF COURSE. But patients hate it. “Don’t give me any more of that stuff.” “I feel like I’m going to die.” “I feel like I have a tornado in my chest.” They love not being in SVT anymore… but they hate how they get there.

 

No Muss! No Fuss! REVERT that SVT!

There’s been a lot floating around in the critical care world about updating the Valsalva technique. Why?

  • Traditional Valsalva success rate is 5-20%
  • REVERT technique gets **43% conversion**!!!!
  • NNT = **3**. That’s HUGELY effective.
  • Free! No cost, no muss, no fuss.
  • ZERO serious adverse events.

How? Have them blow through a straw… then give ’em the Dipsy Doodle!

 

Okay, But What If That Doesn’t Work?

Look, am I saying NOT to EVER give adenosine? No. But for most patients, I think verapamil and diltiazem are better drugs. Why? No tornadoes. Level I-Class A evidence for their use.

  • Diltiazem: 0.25mg/kg IVB sloooowwwllyyyyy; repeat at 0.35mg/kg
  • Verapamil: 2.5-5mg IVB slooooowwwlyyyyyy; repeat at 5-10mg.
  • Pre-dosing with calcium salts (CaCl) can attenuate hypotension

Beta blockers: Evidence here isn’t as good, but they are a viable option.

Yes, they do risk hypotension (verapamil more than diltiazem). Give them slowwwwwlllyyyyyy. Like, over 2 minutes slowly. Or do them as a drip. Monitor BP continually. Be careful.

If You HAVE to Give Adenosine….

  • Ask about caffeine intake before you give the drug. Caffeine attenuates adenosine. (Ironic, considering how many SVTs are caffeine-related!) If a lot of intake, consider Ca++ Channel Blocker (CCB) or increasing the dose.

 

A FlowChart, Then?

SVT

  • SBP <= 90 OR looks shocky?
    • IV
    • Anaesthetise (etomidate, propofol, fentanyl, midazolam, ….)
    • SYNC!!!!!
    • Cardiovert @ 100J, 120J, 150J, 200J
  • SBP > 90?
    • REVERT (have pt blow through a syringe HARD, then lay flat & raise legs)
      • Success? ==> Observe, transport/monitor
      • Failed?
        • IV
        • Can tolerate adenosine with LITTLE TO NO caffeine on board?
          • Yes ==> Give adenosine
            • PREPARE YOUR PATIENT.
              • “You may feel like you’re going to die.”
              • Explain that it slows your heart way down, “you may feel as if you’re going to die, but the feeling will pass quickly”.
            • Give adenosine 6mg, RAPID flush
              • Reveals underlying a-fib/flutter? GO TO CCB
              • No fib/flutter? Repeat adenosine @ 12mg, consider threepeat @ 12mg, RAPID flush
          • Hesitant / Refuses adenosine?
            • No contraindication to CCB?
              • *Give calcium gluconate 1g IVB slooooowwwllyyy > 3 mins (Optional)
              • (OR give CaCl 90mg IVB slooooowwwwly > 3 mins (optional) )
              • Diltiazem: 0.25mg/kg IVB sloooowwwllyyyyy > 2 mins; repeat at 0.35mg/kg
              • Verapamil: 2.5-5mg IVB slooooowwwlyyyyyy > 2 mins; repeat at 5-10mg.
            • Contraindication to CCB?
              • Beta Blocker (labetalol, ….) at appropriate dose
Sources

http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=133&seg_id=2668

http://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/

VIDEO: http://www.thelancet.com/cms/attachment/2035488647/2051082005/mmc2.mp4

http://www.ncbi.nlm.nih.gov/pubmed/20926952

http://www.aliem.com/calcium-before-diltiazem-may-reduce-hypotension-in-rapid-atrial-dysrhythmias/

 

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