Critical Cases - Refractory SVT in the ED!



Step 1 - Modified Valsalva

  • Have the pt lie in semi-recumbent positon
  • Blow into a standard 10 ml syringe as long as they can
  • Lay the patient supine and elevated the legs for one minute
  • Even better, just watch this demo from the 2019 ResusEM conference with Cooper EM intern Eric Hasbun (who needs to work on his core):





 Step 2 - Escalating adenosine doses

  • If standard doses of 6 and 12 mg fail, escalate doses by 6 mg
  • Up to 36 mg have been successful in case reports


Step 3 - Try a slow infusion of a CCB

  • Diltiazem or verapamil may be given as a slow bolus
  • Is at least as successful, if not more successful, than adenosine in terminating SVT
  • May cause hypotension, treat with fluids and/or IV calcium gluconate


Step 4 - If preparing to cardiovert, use propofol as sedative

  • Propofol has terminated a variety of tachyarrythmias in multiple case series
  • Remember to give pain medication as well if cardioversion is necessary (propofol does not help with pain)
  • Only requires 25-50J



Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation 2009; 80:523-528.

Bailey AM, Baum RA, Rose J, Humphries RL. High-Dose Adenosine for Treatment of Refractory Supraventricular Tachycardia in an Emergency Department of an Academic Medical Center: A Case Report and Literature Review. J Emerg Med. 2016 Mar;50(3):477-81.

Appelboam A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015; 386:1747-53