R Efractory a Systole and D Eath F Ollowing the P Rehospital a Dministration of a Denosine

Abstract

In use since the 1980s, adenosine is an effective, safe treatment for narrow-complex supraventricular tachycardias. Well-recognized adverse effects of adenosine include chest pain, flushing, transient asystole, metallic taste, bronchospasm, respiratory arrest, and (rarely) proarrhythmic effects. 1 These adverse effects have always been reported to be transient and overwhelmingly benign. Several prehospital adenosine studies demonstrate benefit with little morbidity and no mortality. 2-4 This is a case of refractory asystole and subsequent death following the prehospital administration of adenosine. CASE REPORTA 38-year-old Asian male, reportedly ill for two weeks, unseen by his family for two days, was found on the floor of his residence with questionable altered mental status by family members. The emergency medical services (EMS) system was notified via 9-1-1 and a paramedic ambulance was dispatched, arriving at the location minutes later. They found an Asian male, alert, sitting upright with family members' support. He was in obvious distress with rapid shallow respirations and single-word responses. Communication was difficult because English was the patient's second language. Both the patient and the family stated that he had no past medical history, was taking no medications, and had no medication allergies. The patient denied shortness of breath; however, he did indicate that he was experiencing palpitations and a vague chest discomfort.Initial vital signs showed a blood pressure of 170/100 mm Hg, a pulse of 180 beats/min, and a respiratory rate of 22 breaths/min. Physical exam found the patient to be alert and oriented to person, place, and time, well hydrated with moist mucous membranes, skin reddened but warm and dry, pupils midsized and sluggish, breath sounds shallow with minimal air movement without wheezing, and peripheral extremities with capillary refill of less than 2 seconds. Jugular venous distension and cardiac sounds were not reported. A three-lead rhythm strip was interpreted to be supraventricular tachycardia and blood glucose was reported to be normal.The patient was placed on 15 L/min of oxygen by nonrebreather mask and transported to the ambulance. Following a carotid massage, the heart rate was noted to have increased to 230 beats/min with a narrow QRS complex. An IV was established and the patient was given 6 mg of adenosine as per written protocol. Over a period of 30-90 seconds, the patient's heart rate progressed from 230 beats/min to bradycardia and finally to asystole. After approximately 1 minute, cardiopulmonary resuscitation (CPR) was initiated and the patient was intubated with a 7.0 endotracheal tube at 22 cm against the teeth with good bilateral breath sounds. Advanced Cardiac Life Support (ACLS) was initiated by written protocol. Multiple rounds of epinephrine and atropine were injected, for a total of 16 mg of epinephrine (given as an initial dose of 1 mg followed by three doses of 5 mg as per protocol) and 3 mg (given as three separate 1mg doses as per protocol), respecti...

Cardiac Arrest After Adenosine Administration in Compensatory Tachycardia: A Case Report

“…Immediately following the administration of adenosine, the patient went into cardiac arrest. In our review of the literature, there have been only three documented cases of death following adenosine administration in the prehospital setting and none in the emergency department [3,4]. Given the prevalence of use by EMS, this case serves as an important reminder of the potential consequences of adenosine administration in the incorrect clinical scenario and stresses the importance of accurate prehospital EKG interpretation and correct patient selection to prevent adverse outcomes.…”

Adenosine and the Cardiovascular System: The Good and the Bad

“…This effect may be used for the diagnosis of unexplained syncope (see below). Sometimes, the administration of exogenous adenosine has resulted in asystole followed by myoclonic jerk or death [93,94]. It seems that exogenous adenosine may cross the feto-placental barrier since fetal bradycardia was observed after adenosine administration for maternal supraventricular tachycardia [95].…”

Proarrhythmic effects of adenosine: a review of the literature

“…5 In one patient treated with adenosine out of hospital asystole was fatal. 6 Prolonged sinus arrest and bradycardia after the administration of adenosine have resulted in syncope 7 and seizures, 8 in one case in a patient undergoing myocardial perfusion imaging. 9 Fetal bradycardia has also been reported after treatment of a maternal supraventricular tachycardia with adenosine.…”