ADENOSINE ??

**canoehead, BSN, RN** · Jun 7, 2009

Does my IVF run faster if I elevate the arm????

Presumably the fluid inside the arm will flow faster going downhill, and you should have already gotten the med and flush in before raising the arm. I don't think it matters much, but I do like to have physical contact with the patient for that feeling of doom moment. I don't know if it helps them, but I hate to frighten someone so much without trying to provide some comfort.

PAERRN20 · Jun 9, 2009

Hmm...I was taught to raise the arm in ACLS too. If I know I am going to be giving Adenocard I put a 20g in the AC. I know floor nurses hate this spot but I'm an ER AC loving nurse. (Sorry!! Hehehe) Anyways my reasoning behind this is the the AC is a large vein, lots of flow, closer to the heart than say a hand vein, and the 20g can tolerate a rapid 20cc bolus much better than something below the wrist.

We don't have to have a doctor in the room while we push Adenocard. In fact they rarely are. The patient is on the monitor and the EKG machine is near.

JDCitizen · Jun 9, 2009

So just how high does ACLS teach to raise the arm? :thnkg:

jeremyRN · Jun 9, 2009

I was never taught the arm raise either. I was taught that the IV should be an 18 or 20 gage in the AC if possible (large vessel closer to the heart). I usually have a 3 or 12 lead running too, just bacause it is cool to look at when you have a successful conversion.

Editorial Team / Moderator · Jun 9, 2009

I usually have a 3 or 12 lead running too, just bacause it is cool to look at when you have a successful conversion.

Yep, I leave them hooked up to the 12-lead and have it running a continuous printout (we just have to hit the "manual" button on ours).

getoverit, BSN, RN, EMT-P · Jun 9, 2009

I've taught ACLS since 1994 and we don't teach to raise the arm. Every once in awhile, one of the instructors will mention it but it's definitely not a point we try to "hammer home". Like Gila said, your patient should be stable anyway. I rarely ever push Adenosine anymore, usually we give Labetolol or Cardiazem. We use adenosine to slow down a stable rhythm in order to get a better looking 12 lead.

Last night my patient went into an SVT @ 170s, mildly hypertensive, desatting a little bit...anyway, I gave him two boluses of Adenosine through a central line so you know it was dumping out right into his SVC but there wasn't so much as a blip on the monitor. It's weird, but I've pushed adenosine maybe 30 times in 17 years (not very much), but about 25% of the time it has absolutely no effect at all....and I've never raised an arm except on a pediatric patient, just given the 20cc flush each time and hoped for the best.

JDCitizen · Jun 9, 2009

Seems to be no consensus except for:

- Better to have large bore

- Push fast

- Flush fast

Insightful to read about the different policy/procedures....

So does everyone have the crash cart in the room or next to the room, never moved??? Over the years I have seen the conversion go the wrong way. I have seen immediate response save the patient. I have seen immediate response not save the patient.

Well since it was mentioned it is kind of strange the difference in policy of adenosine vs starting cardizem, etc.. (At least in the facilities I have worked at).

getoverit, BSN, RN, EMT-P · Jun 9, 2009

yeah, crash cart/defib/etc is at the ready whenever I've pushed it. fortunately, I"ve not had any personal experience with sustained asystole (maybe 4-6 seconds at the most then a rhythm returned).

and yeah, it is a different policy with diltiazem.

cookienay · Jun 10, 2009

Am I the only sick one who loooves giving Adenosine?? he-he

Anyway, never heard of the arm raising. We always tell the patient you are going to feel like crap for a second but it should get better (and the nurse best be prepared if it does not). personally, i have never seen sustained asystole with Adenosine, and it has worked every time I have used it for SVT. Of course, it did not work for Afib RVR, but it did allow us to see the patient was actually in AF with RVR. happy slamming, everyone.

Roy Fokker, BSN, RN · Jun 10, 2009

If you picked up a provider manual from the AHA for ACLS including the most current you would find that you should perform the arm elevation manuever.

I'll try to track down the latest version of the manual at work this week. I don't recall reading about such a maneuver but I could be mistaken.

Now that said...over the years I've learned that in ACLS there can be significant lags between when ACLS incorporates the most current research into their guidelines/courses...and sometimes the recommendations aren't supported by the strongest of evidence, just the best available evidence at the time the guidelines were formulated.

That's the story of 'science' in general. We don't always have the 'best picture' but often go by 'the closest approximation'.

I don't know whether anyone has ever demonstrated in a research paper the superiority of arm elevation in converting SVT with adenocard over nonelevation----but I DO know it's a part of ACLS and should be taught.

I was going to ask a question about the 'effectiveness' of said maneuver - but someone else beat me to it:

So just how high does ACLS teach to raise the arm? :thnkg:

If 'raising the arm helped', just how much should we raise it to?

I am curious do any of you have the 12 lead on while giving adenosine?

As much as possible in the ED - we like to try and print/capture as many 12 lead EKGs during the procedure (we only have 4 portable 12 lead machines). Of course every patient (who presents with such symptoms) has already had a 12 lead EKG done and is already on the wall 3/5-lead monitor...

In trying to reason out this arm raising thing, I got to thinking that what good is arm raising when the veins have valves?
Am I just too tired, or does this make any sense?

Venous valves "open" towards the heart (think Trendelenburg for example - how do we 'shunt' blood towards central circulation away from the periphery?).

...but DOES IT REALLY MATTER????

See my response to GilaRN's post.

Does my IVF run faster if I elevate the arm????

Of course it does! Didn't anyone teach your to elevate extremities when you have a sluggish IV site?!! There are certain angles involved you know....

Agree. At the end of the day, this is not a big deal compared to all the other knuckle-headed things I have seen.

mwboswell and GilaRN,

You've echoed my thoughts exactly!

IMHO - the "raising of the arm" is rendered redundant because of the 20 ml saline flush that accompanies every Adenosine administration. Furthur more, given Adenosine's fleeting half-life; by the time the med and the flush have been administered it's a little too late to wonder/worry about "increasing venous return to aid in drug delivery by raising the arm".

So just how high does ACLS teach to raise the arm? :thnkg:

Raise arms by 136 degrees and 12.5 minutes....

What? You don't believe me?

ACLS protocols you know...

cheers,

Virgo_RN, BSN, RN · Jun 10, 2009

I'll try to track down the latest version of the manual at work this week. I don't recall reading about such a maneuver but I could be mistaken.

I have the most recent edition, and it's in there.

Aneroo, LPN · Jun 11, 2009

I was never taught to raise the arm either.
I am curious do any of you have the 12 lead on while giving adenosine? We do that in my neuro ICU, plus the paddles, and wall mounted EKG.

Yes, we did a continuous 12 lead during admin. This way if they were in a normal rhythm for just a moment we'd have it captured before they went back into whatever they were in. We also had to have the attending (not just the resident) at the bedside.

I love and hate adenosine! I love the rush of giving it, I hate standing there waiting for the heart to start back and the sheer panic on the patients face. I've only had one where I really thought we were going to have to start CPR, and then it started back.