Pii: s0196-0644(99)70392-6

P E D I A T R I C S / O R I G I N A L C O N T R I B U T I O N
Adenosine and Pediatric SupraventricularTachycardia in the Emergency Department: Pediatric Emergency Medicine
Study objective: To determine the frequency of successful
Collaborative Research
cardioversion and the adverse effects of adenosine treatment in Children’s Hospital, Houston, TX‡; Committee
pediatric emergency department patients with supraventricular Joseph D Losek, MD*
Erin Endom, MD‡
Hospital of Michigan, Detroit, MIII; Methods: This was a multicenter descriptive study with both
Ann Dietrich, MD§
Gail Stewart, DOII
prospective (convenience sample) and retrospective (chart review) William Zempsky, MD¶
patient entry. The setting was 7 urban pediatric EDs with a yearly Kathy Smith, MD#
census range of 22,000 to 70,000 visits. Pediatric patients 18 years of age and younger who received intravenous adenosine for March 2, 1998. Revision received August 24, 1998. Accepted for publication September 8, 1998. Results: Six investigators from 7 pediatric EDs entered 82
Address for reprints: Joseph D
patients with 98 presumed SVT episodes (52 prospective and 46 Losek, MD, Children’s Hospitals retrospective) into the study. Twenty-five episodes occurred in and Clinics—St Paul, 345 NorthSmith Avenue, St Paul, MN 55102; children younger than 1 year of age. Eight patients had congenital heart disease, 59 had a history of SVT, 43 were taking cardiacmedications (digoxin in 27), 13 had a history of asthma, and 25 Copyright 1999 by the AmericanCollege of Emergency Physicians. presented in compensated cardiogenic shock. A total of 193intravenous doses of adenosine were administered; doses were classified as low (<.1 mg/kg [n=18]), medium (.1 to <.2 mg/kg 47/1/94880
[n=116]), or high (≥.2 mg/kg [n=59]). The dose range was .03 to.5 mg/kg, and only 2 doses were higher than .3 mg/kg. A total of95 patient-events were determined to be SVT, all but 5 of whichwere atrioventricular (AV) node–dependent; 3 events were ven-tricular tachycardia. The overall cardioversion success rate ofadenosine was 72% (71/98), and that for AV node–dependentSVT was 79% (71/90). Cardioversion was successful for 4patient-events at a low dose, 44 at a medium dose, and 23 ata high dose of adenosine. Adverse effects occurred in 22 patients,and no patient had bronchospasm or hemodynamically signifi-cant arrhythmia.
Conclusion: Intravenous administration of adenosine led to
successful cardioversion in 72% of pediatric ED patient-events
that were presumed to be SVT. A dose range of .1 to .3 mg/kg
was found to be most effective. Adenosine was not associated
with significant adverse effects.
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[Pediatric Emergency Medicine Collaborative Research Committee, shock (hypotension for age), atrial fibrillation, atrial flutter Losek JD, Endom E, Dietrich A, Stewart G, Zempsky W, Smith K: or sick sinus syndrome, use of carbamazepine and dipyri- Adenosine and pediatric supraventricular tachycardia in the damole (both are adenosine uptake inhibitors and prolong emergency department: Multicenter study and review. Ann the effects of adenosine2), or use of methylxanthines (whichdecrease the effects of adenosine by blocking adenosine receptors2). SVT was defined as a narrow QRS complextachycardia with a fixed RR interval, absence of normal Pwaves, and a rate exceeding the upper limit of sinus tachy- cardia for age (< 1 year, 180; 1 to 2 years, 150; 3 to 12 years, Supraventricular tachycardia (SVT) occurs in 1 of 250 to 1 of 1,000 children, making it the most common arrhyth- Demographic information included age, sex, race, name mia in the pediatric population. Adenosine is an endoge- of treating hospital, date of treatment, presence of structural nous nucleoside that transiently blocks atrioventricular (AV) heart disease (except patent ductus arteriosus or sponta- conduction in the heart.1-5 Almost 90% of SVT in chil- neously closed ventricular septal defect), previous cardiac dren is based on a re-entrant mechanism.6 For these surgery (except closure of patent ductus arteriosus in a reasons, adenosine should be effective for the termina- premature infant), previous ECG-documented SVT, medi- tion of most pediatric SVT episodes. Reports of the use of cations taken within the past 24 hours, and history of adenosine in children are limited to hospitalized patients, wheezing requiring bronchodilators within the past year.
many of whom received adenosine during electrophysio- Clinical interventions recorded before treatment included logic testing.7-14 No studies have focused on the use of vital signs, symptomatic complaints, and physical exami- adenosine in the pediatric emergency department, where many episodes of SVT are treated. Despite the lack of Compensated cardiogenic shock was defined as normal studies, adenosine has become first-line therapy for systolic blood pressure for age (< 2 years, 70; 2 to 12 years, SVT in the pediatric patient who presents to the ED.15 80; 13 to 18 years, 90 mm Hg) or higher, associated with 1 or The purpose of this study was to determine the frequency more of the following: respiratory distress, altered level of of successful cardioversion and the adverse effects of consciousness, anxiety, irritability, diaphoresis, pallor, or adenosine treatment in pediatric ED patients with SVT.
hepatomegaly. Respiratory distress was defined as the The associations of several clinical variables with success- presence of 1 or more of the following: retractions, rales, ful cardioversion and with adverse effects were evaluated.
or tachypnea (breaths per minute) for age (<1 year, >60; 1to 2 years, >50; 3 to 12 years, >40; 13 to 18 years, >30).
Documentation of interventions included a 12-lead ECG before and after conversion to sinus rhythm for patients Through the Collaborative Research Committee, Emergency with unknown conduction mechanism of SVT, a 12-lead Medicine Section, American Academy of Pediatrics, 6 of ECG or lead II rhythm strip during conversion (reading of 23 pediatric emergency medicine physician committee ECGs was not blinded), number of adenosine doses, adeno- members offered to participate in this study. The study sine dosage, and other modes of treatment (drugs versus protocol was approved by the review board of each center synchronized electrical cardioversion).
at which patients were entered prospectively. Consent beyond Doses of adenosine were administered by rapid intra- the standard consent for treatment in the ED was waived venous bolus followed by 5 to 10 mL of flushing with because adenosine is the drug of choice for SVT.
normal saline solution. The recommended first dose was Children from birth to 18 years of age who received .1 mg/kg, with a maximum dose of 6 mg. Subsequent intravenous adenosine for treatment of presumed SVT in doses were .2 mg/kg, with a maximum single dose of 12 mg.
a participating pediatric ED were eligible. Patients were Adenosine treatment success was defined as SVT converted enrolled prospectively by convenience sample and retro- to sinus rhythm for a minimum of 5 minutes.
spectively by chart review based on the presence of Clinical The following were considered systemic adverse effects Modification Code 427 (cardiac dysrhythmias) of the of adenosine if they occurred within 5 minutes of admin- International Classification of Diseases, 9th revision. ED istration: bronchospasm, dyspnea, cough, chest pain, census logs were not reviewed. Patients were excluded flushing, headache, nausea, or vomiting. Cardiac adverse from the study if one or more of the following conditions effects included the following if they were present for longer were present: congestive heart failure with uncompensated than 10 seconds after adenosine administration: asystole, A N N A L S O F E M E R G E N C Y M E D I C I N E 3 3 : 2 F E B R U A R Y 1 9 9 9
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bradycardia for age (<2 years, <100; 2 to 12 years, <70; 13 included 2 cases of atrial tachycardia, 1 automatic atrial to 18 years, <60), AV block, atrial fibrillation, atrial flutter, tachycardia, 1 ectopic atrial tachycardia, and 1 junctional ventricular tachycardia, or ventricular fibrillation.
tachycardia. Twenty-two (24%) of the AV node-dependent The medical records were reviewed to ascertain type SVT events were caused by Wolff-Parkinson-White (WPW) and mechanism of tachycardia, and therefore the exclu- sions for arrhythmias were determined retrospectively.
One to 4 doses of adenosine were administered per Tachycardias were classified as ventricular or supraven- episode. Of the 193 doses of adenosine administered, 18 tricular. Supraventricular tachycardia was further divided were classified as low dose (<.1 mg/kg), 116 as medium into AV node–dependent and non–AV node-dependent dose (.1 to < than .2 mg/kg), and 59 as high dose (≥.2 types, the latter including junctional tachycardia, ectopic mg/kg). The range was .03 to .5 mg/kg, or .23 to 12 mg.
atrial tachycardia, atrial flutter, atrial fibrillation, sinus Only 2 doses were greater than .3 mg/kg. The patient was tachycardia, and sinus node reentry.
initially treated with a low dose in 16 episodes, with a Summary statistics included absolute numbers and medium dose in 78 episodes, and with a high dose in 4 percentages for successful conversion and adverse effects.
episodes. Additional doses were equal to or greater than Univariate analyses (χ2 or Fisher’s exact test, 2-tailed), with preceding doses for patients receiving more than 1 dose.
success as an outcome, were used to identify the individual The number of doses administered per patient event aver- variables with the greatest association. A probability value aged 2.44, 1.90, and 1.5 for patients who initially received lower than .05 was considered to be indicative of a sig- low, medium, and high doses, respectively.
The overall success rate of adenosine per patient-event in presumed SVT was 71 (72%) of 98. Of the 90 AVnode-dependent SVT events, 71 (79%) were treated suc- cessfully. In patients with non–AV node-dependent SVT or Six pediatric emergency medicine physicians from 7 urban ventricular tachycardia, cardioversion with adenosine pediatric EDs (annual census, 22,000 to 70,000 visits) was not successful. Demographic, clinical, and therapeutic participated. There were 82 patients and a total of 98 pre- factors in relation to success of treatment are summarized sumed SVT events. One patient had 5 events, 3 patients in Table 2. There were no significant associations between had 3 events each, and 6 patients had 2 events each. There any of these factors and treatment success. The medium- and were 52 prospective and 46 retrospective patient-events.
high-dose ranges of adenosine resulted in greater success The range of patient entry dates for each investigator is rates than did the low-dose treatment. Among the 10 patients presented in Table 1. Prospective and retrospective cases with multiple events, cardioversion with adenosine treatment were combined, and total patient-events were used for data analysis. No patient was excluded because of con- Adverse effects occurred in 22 of the 98 cases; no patient current use of dipyridamole, carbamazepine, or methyl- with more than 1 event had recurrent adverse effects. The most common noncardiac adverse effect (8 patients) was Of the 98 patient-events, 54 (55%) occurred in boys.
Sixty-six occurred in white patients, 22 in black patients, 6in Hispanics, and 4 in patients of other ethnic backgrounds.
Twenty-five events (26%) occurred in children younger Method of patient entry and dates. than 1 year of age. In 8 cases (8%), congenital heart disease waspresent; 7 patients (7%) had undergone cardiac surgery; and43 (44%) were taking cardiac medications, including 27 Patients Entered
Investigator
(Prospective/Retrospective)
Date Range
who were taking digoxin. In 59 cases (60%), there was ahistory of SVT; in 13 (13%), there was a history of asthma.
In 25 events (26%), the patient presented in compensated cardiogenic shock. Vagal maneuvers were performed in 45 cases; in 6 of these, the rhythm temporarily converted to sinus Ninety-five events were SVT, and 3 were ventricular tachycardia. Of the SVT events, 90 were AV node-depen- dent and 5 were non–AV node-dependent. The latter group F E B R U A R Y 1 9 9 9
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vomiting (Table 3). Dyspnea occurred in 2 patients, neither with the following treatments: procainimide (3), verapamil of whom had a history of asthma. Both patients with arrhyth- (3), β-blocker (2), digoxin (2), flecainide (2), further doses mia had self-limited bradycardia (duration, 5 and 15 seconds) of adenosine during hospitalization (1), electrical syn- before successful conversion to sinus rhythm. The adverse chronized cardioversion (1), esophageal overdrive pacing effect probability values were not determined due to the low (1), spontaneous cardioversion (1), and unknown (3). There prevalence of adverse effects. Trends included a greater rate were no deaths in this study population.
of adverse effects in children 1 year of age or older, in thosewho had undergone cardiac surgery, and those who were not in cardiogenic shock (Table 2). The number of adverseevents was similar in the medium- and high-dose groups The overall success rate for conversion of 98 presumed SVT and did not depend on the number of doses received.
events in 82 pediatric patients treated in the ED was 72%.
The 19 AV node–dependent SVT events unsuccessfully This compares with a rate of 77% (90/117) reported by treated with adenosine were converted to sinus rhythm Till et al10 in 50 hospitalized pediatric patients (1 to 17 Patient characteristics and results of treatment with adenosine. Successful Cardioversion
Adverse Effects
Category
Patient-Events
*Fisher’s exact test, 2-tailed.
†Total number of doses given.
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years of age). Till et al reported an 86% (88/102) success rate ing aminophylline and caffeine required .4 to .8 mg/kg for AV node–dependent SVT, compared with 79% in our per dose of adenosine for cardioversion of SVT after study. Two ED studies of adult patients showed overall multiple doses less than .4 mg/kg were unsuccessful.
success rates of 54% and 85% and AV node–dependent In our study, 32 adverse effects occurred in 22 (22%) SVT success rates of 85% and 96%.16,17 Five prehospital of 98 patient-events. Eight patients had more than 1 care studies of adult patients reported adenosine success adverse effect. Vomiting, the most common adverse rates ranging from 45% to 68%, with AV node–dependent effect, was reported in 8 patients. No sustained arrhythmia or bronchospasm was observed in our study. Overholt et Our study, like others, showed no decrease in adenosine al11 reported adverse effects in 6 pediatric patients (25%), effectiveness in the presence of WPW, congenital heart including 5 with dyspnea, flushing, or irritability and 1 with disease, or concurrent digoxin use.8,10 The 68% success bradycardia. No other pediatric study has delineated rate for children younger than 1 year of age was lower than nonserious adverse effects. Studies of adult patients that the rate of 74% for older children, but the difference was not listed nonserious adverse effects and limited the maximum significant. This is consistent with a report by Dorostkar et al,14 adenosine dose to 12 mg have reported adverse effects rates who indicated a 60% success rate for infants. Possible expla- of 9.3% to 26.6%. In these studies, the most common adverse nations for this lower success rate are that smaller-gauge effect was chest pain or discomfort; this complaint accounted intravenous catheters used in infants may not permit rapid for 36% of the nonserious adverse effects. These effects were delivery of adenosine and that the AV nodes of infants may transient (<1 min) and were associated with successful be relatively more resistant to adenosine.
The effectiveness of adenosine in the treatment of pedi- Factors in our study that had a greater rate of adverse atric patients with compensated cardiogenic shock (nor- effects of adenosine treatment were age 1 year or older, mal systolic blood pressure for age) secondary to SVT has absence of cardiogenic shock, and cardiac surgery. The not been reported previously. We found the success rate of greater rate of adverse effects in older children can adenosine treatment for 25 patients in compensated car- probably be attributed to the subjective nature of adeno- diogenic shock to be similar to the rate for patients without sine’s adverse effects (nausea, light-headedness, dizziness, cardiogenic shock (80% versus 70%, respectively). No impression of impending doom, weakness, headache, and significant adverse effects occurred in patients with com- chest pain or discomfort). Younger children would be less pensated cardiogenic shock. Studies of adults with SVT likely to report these adverse effects. The greater rate of and associated hypotension (systolic pressure <90 mm Hg) adverse effects in patients with noncardiogenic shock is reveal that the presence of hypotension does not increase possibly related to the fact that the signs of cardiogenic the incidence of adverse effects or alter the effectiveness shock are similar to those of adverse effects, so that adverse of adenosine in achieving cardioversion and normal bloodpressure.16,18,22,23 In our study, the rate of success for medium- or high-dose adenosine (≥.1 mg/kg) was 38%, compared with 22% for Type and frequency of adverse effects. low-dose adenosine (<.1 mg/kg). Also, initial low-dosetreatment resulted in a greater number of doses being No. of Patients
given than when the starting dose was .1 mg/kg or higher.
Of the 8 doses of .3 mg/kg or more (administered to 8 differ- ent patients), only 1 (at .3 mg/kg) was successful. Five of these 8 patients had AV node–dependent SVT, and 3 had VT. The Emergency Cardiac Care Committees and the American Heart Association recommend a dose of .1 to .2 mg/kg.24 Our study supports a dose range of .1 to .3 mg/kg (maximum, 12 mg) as most effective for treat- ment of SVT. If higher doses are unsuccessful, a non–AV node–dependent arrhythmia should be considered.
Higher doses may be necessary for patients receiving theophylline or aminophylline. Berul25 reported that a 16-day-old female infant with WPW who was receiv- F E B R U A R Y 1 9 9 9
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effects are more apparent in the patients without noncar- and inhaled albuterol. In contrast to adenosine-related bronchospasm, Cook et al31 reported conversion to sinus The greater rate of adverse effects among patients with tachycardia with administration of .1 mg/kg adenosine in previous cardiac surgery is consistent with reports showing a 4-year-old with albuterol-induced SVT. None of the that cardiac transplantation patients are hypersensitive to patients in our study had bronchospasm, and this group adenosine. Ellenbogen et al26 studied the effects of adeno- included 13 asthmatic patients. From our experience, sine in 28 orthotopic cardiac transplantation patients and asthma is not a contraindication to adenosine, although found that the denervated transplanted donor sinus and AV emergency physicians should be prepared to treat immedi- nodes demonstrated an increased duration of electrophys- ate bronchospasm and to consider delayed bronchospasm iologic effect. In a case series by Crosson et al27 of 38 chil- when managing asthmatic patients who receive adeno- dren with 50 episodes of SVT undergoing electrophysiologic testing, 1 cardiac transplantation patient became asystolic In our study, 3 patients (3%) had ventricular tachycardia with adenosine and required 1 minute of resuscitation.
misinterpreted as SVT. Two patients received doses of .1, Because of these findings, the recommended adenosine .2, and .3 mg/kg, and 1 patient received doses of .2 and .3 dose given to transplantation patients to treat SVT is mg/kg. One patient complained of chest pain, and none of approximately 67% to 80% of the generally recommended these patients had successful cardioversion with adenosine.
dose.26,27 Our findings indicate that this reduced dose Crosson et al27 described 2 children (5%) with ventricu- recommendation may also be applicable to children who lar tachycardia misinterpreted as SVT. One had successful have previously undergone cardiac surgery.
cardioversion with adenosine, and no adverse effects Clinically significant cardiac adverse effects associated occurred. In prehospital and ED studies of adult patients, with adenosine are extremely uncommon in children but 10 (1.4%) of 691 patients had ventricular tachycardia have been reported. ED personnel must be prepared to treat misinterpreted as SVT and were treated with adenosine.
life-threatening arrhythmias when administering adeno- Conversion was successful in 1 patient, and no adverse sine. In our report, 2 patients had episodes of bradycardia effects were reported.16-22 Therefore adenosine treat- lasting less than 1 minute. Till et al10 reported that 1 patient ment of ventricular tachycardia misinterpreted as SVT experienced a 40-second bradycardic adverse effect. In a does not appear to be associated with serious adverse case series of 25 pediatric patients (age range, 6 hours to 17 years), a 10-year-old child with Down’s syndrome, AV Our study has 2 limitations. First, the original design canal, and pulmonary hypertension had sinus bradycar- was prospective, but retrospective patients were added to dia for 2 to 3 minutes and required temporary pacing.11 increase the study population and to include patients not Ventricular fibrillation is another, very uncommon adverse entered prospectively. The 2 centers that entered patients reaction to adenosine. Mulla and Karpawich28 reported only prospectively (21 patient-events) may have missed that an 8-day-old child with WPW treated with digoxin eligible patients. Therefore the results of this study might received .2 mg/kg of adenosine for an SVT episode after not be generalizable to the target population (pediatric no response was obtained with smaller doses. The patient patients with presumed SVT presenting to the ED). Second, had asystole for 1 second, followed by ventricular fibrilla- clinical factors not recorded in the medical records of tion and hypotension that was converted to sinus rhythm patients entered into the study retrospectively were con- sidered to be negative. For this reason, the true number of The most serious noncardiac adverse effect of adenosine nonserious adverse effects among such patients may have is bronchospasm. Adenosine causes bronchospasm by been greater than reported, although the rate of adverse enhancing the release of preformed mediators from mast effects was similar for patients entered retrospectively (20%) cells via the adenylate cyclase receptor.29 Mast-cell stimu- and those entered prospectively (25%).
lation can cause immediate or delayed bronchospasm.
In summary, adenosine is effective treatment for children Adenosine has not been associated with bronchospasm in who present to an ED with presumed SVT. Adenosine doses patients who do not have asthma. DeGroff and Silka30 of .1 to .3 mg/kg (maximum dose, 12 mg) were more suc- described a 13-year-old child with asthma who had had no cessful than doses of less than .1 mg/kg. Life-threatening asthma episodes in 3 years but experienced severe bron- adverse effects of adenosine treatment were not found in chospasm 90 seconds after a 12-mg dose of intravenous this study. However, emergency physicians must be pre- adenosine during electrophysiologic testing. The bron- pared to treat hemodynamically compromising arrhyth- chospasm was reversed with subcutaneous epinephrine mias for all patients and immediate or delayed bron- A N N A L S O F E M E R G E N C Y M E D I C I N E 3 3 : 2 F E B R U A R Y 1 9 9 9
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26. Ellenbogen KA, Thames MC, DiMarco JP, et al: Electrophysiological effects of adenosine in chospasm for asthma patients when administering the transplanted human heart: Evidence of supersensitivity. Circulation 1990;81:821-828.
27. Crosson JE, Etheridge SP, Milstein S, et al: Therapeutic and diagnostic utility of adenosineduring tachycardia evaluation in children. Am J Cardiol 1994;74:155-160.
We thank Alice Sather for her help in the preparation of this manuscript.
28. Mulla N, Karpawich PP: Ventricular fibrillation following adenosine therapy for supraventric-ular tachycardia in a neonate with concealed Wolff-Parkinson-White syndrome treated withdigoxin. Pediatr Emerg Care 1995;11:238-239.
29. Burkhart KK: Respiratory failure following adenosine administration. Am J Emerg Med 1. Camm AJ, Garratt CJ: Adenosine and supraventricular tachycardia. N Engl J Med 30. DeGroff GG, Silka MJ: Bronchospasm after intravenous administration of adenosine in a 2. Adenosine. The Medical Letter 1990;32:63.
patient with asthma. J Pediatr 1994;125:822-823.
3. Dimarco JP, Miles W, Akhtar M, et al: Adenosine for paroxysmal supraventricular tachycar- 31. Cook P, Scarfone RJ, Cook RT: Adenosine in the termination of albuterol induced supraven- dia: Dose ranging and comparison with verapamil. Ann Intern Med 1990;113:104-110.
tricular tachycardia. Ann Emerg Med 1994;24:316-318.
4. Garratt CJ, Linker N, Griffith M, et al: Comparison of adenosine and verapamil for termina- 32. Herbert ME, Votey SR: Adenosine in wide-complex tachycardia. Ann Emerg Med tion of paroxysmal junctional tachycardia. Am J Cardiol 1989;64:1310-1316.
5. Dimarco JP, Sellers TD, Berne RM, et al: Adenosine: Electrophysiologic effects and thera- peutic use for terminating paroxysmal supraventricular tachycardia. Circulation 1983;68:1254-1263.
6. Campbell RM, Dick M, Rosenthal A: Cardiac arrhythmias in children. Annu Rev Med 7. Ros SP, Fisher EA, Bell TJ: Adenosine in the emergency management of supraventricular tachycardia. Pediatr Emerg Care 1991;7:222-223.
8. Greco R, Musto B, Arienzo V, et al: Treatment of paroxysmal supraventricular tachycardia in infancy with digitalis, adenosine 5´ triphosphate, and verapamil: A comparative study.
Circulation 1982;66:504-508.
9. Clark B, Rowland E, Barnes PJ, et al: Rapid and safe termination of supraventricular tachy- cardia in children by adenosine. Lancet 1987;1:299-301.
10. Till J, Shinebourne EA, Rigby ML, et al: Efficacy and safety of adenosine in the treatment ofsupraventricular tachycardia in infants and children. Br Heart J 1989;62:204-211.
11. Overholt ED, Rheuban SK, Gutgesell HP, et al: Usefulness of adenosine in the treatment ofsupraventricular tachycardia in infants and children. Am J Cardiol 1988;61:336-340.
12. Chow AE, Noble-Jameson C: Termination of paroxysmal supraventricular tachycardia byintravenous adenosine in a child. Anaesthesia 1989;44:322-323.
13. Rossi AF, Burton DA: Adenosine in altering short and long term treatment of SVT in infants.
Am J Cardiol 1989;64:685-686.
14. Dorostkar PC, Dick M, Serwer GA: Failure of adenosine to terminate supraventricular tachy-cardia in neonates [abstract]. Am J Cardiol 1993;72:501.
15. Zempsky WT, Dick M: Acute SVT: The case for adenosine. Contemp Pediatr 1993;10:87-97.
16. Marco CA, Cardinale JF: Adenosine for the treatment of supraventricular tachycardia in theED. Am J Emerg Med 1994;12:485-488.
17. Cairns CB, Niemann JT: Intravenous adenosine in the emergency department managementof paroxysmal supraventricular tachycardia. Ann Emerg Med 1991;20:717-721.
18. McCabe JL, Adhar GC, Menegazzi JJ, et al: Intravenous adenosine in the prehospital treat-ment of paroxysmal supraventricular tachycardia. Ann Emerg Med 1992;21:358-361.
19. Madsen CD, Pointer JE, Lynch TG: A comparison of adenosine and verapamil for the treat-ment of supraventricular tachycardia in the prehospital setting. Ann Emerg Med 1995;25:649-655.
20. Furlong R, Gerhardt RT, Farber P, et al: Intravenous adenosine as first-line prehospital man-agement of narrow-complex tachycardias by EMS personnel without direct physician control.
Am J Emerg Med 1995;13:383-388.
21. Lozano M, McIntosh BA, Giordano LM: Effect of adenosine on the management of supraven-tricular tachycardia by urban paramedics. Ann Emerg Med 1995;26:691-696.
22. Gausche M, Persse DE, Sugarman T, et al: Adenosine for the prehospital treatment of parox-ysmal supraventricular tachycardia. Ann Emerg Med 1994;24:183-189.
23. Melio FR, Ballon WK, Newton E: Successful conversion of unstable supraventricular tachy-cardia to sinus rhythm with adenosine. Ann Emerg Med 1993;22:709-713.
24. Pediatric Advanced Life Support, part IV. JAMA 1992;268:2262-2275.
25. Berul CI: Higher adenosine dosage required for supraventricular tachycardia in infantstreated with theophylline. Clin Pediatr 1993;32:167-168.
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