J Emerg Med
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Review Case Reports
High-dose Adenosine for Treatment of Refractory Supraventricular Tachycardia in an Emergency Department of an Academic Medical Center: A Case Report and Literature Review.
Symptomatic tachycardia is a common admission diagnosis in the emergency department (ED). This can be a life-threatening condition and requires immediate attention. Supraventricular tachycardia (SVT) is commonly treated with adenosine, and successful treatment is limited to atrioventricular (AV) node-dependent SVTs as adenosine causes a transient heart block. However, there are limited data available for instances when the recommended dosing regimen (6 mg, 12 mg, 12 mg) fails to terminate SVT. ⋯ A 33-year old man was evaluated in the ED with an electrocardiogram revealing a regular narrow complex tachycardia with a heart rate of 180 beats/min and a rhythm consistent with SVT. He reported experiencing 3 days of fatigue, myalgias, palpitations, and dyspnea on exertion, but was otherwise hemodynamically stable. Attempts at chemical cardioversion with standard doses of adenosine (6 mg, 12 mg, and 12 mg) were given without success. After consultation with the cardiology service, additional doses of 24 mg and then 36 mg of adenosine were administered. The last dose of 36 mg produced sustained conversion and return to a normal sinus rhythm. The patient later underwent radiofrequency ablation of a left-sided orthodromic reciprocating accessory pathway. After 3 months of medical management, the patient had an implantable cardiac defibrillator placed for prevention of sudden cardiac death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Each case of SVT demands immediate attention from an emergency physician. It is imperative that providers be aware of the limitations of adenosine and when it may be appropriate to deviate from standard dosing recommendations. This is in addition to collaborating with an expert in cardiac electrophysiology when initial management tactics are not successful.
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Influenza is an acute respiratory virus that results in significant worldwide morbidity and mortality each year. As emergency physicians, we are often the first to encounter patients with seasonal influenza. It is therefore critical that we draw on the most recent and relevant research when we make clinical decisions regarding the diagnosis, treatment, and prophylaxis of this disease. ⋯ Influenza vaccine efficacy continues to range between 40% and 80%. Vaccination has the potential to decrease disease severity and is recommended for individuals older than 6 months of age. If resources permit, vaccination can be offered to patients presenting to the emergency department. Rapid antigen detection for influenza is a simple bedside test with high specificity, but generally low sensitivity. If a patient presents with a syndrome consistent with influenza and has negative rapid antigen detection, they should either receive a confirmatory reverse transcriptase polymerase chain reaction or be treated as if they have influenza. Treatment with neuraminidase inhibitors can decrease the duration of influenza and is recommended in hospitalized patients, or in those with high risk of complications.