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Date: May 16th, 2018

Reference: Beltaief K et al. Acupuncture versus titrated morphine in acute renal colic: a randomized controlled trial. J Pain Res. 2018

Guest Skeptic: Dr. Tony Seupaul  is the Chairman of the Department of Emergency Medicine, University of Arkansas. Dr. Cordell Cunningham is a PGY 2 in Emergency Medicine at University of Arkansas for Medical Sciences

Case: A 51-year-old man presents to the emergency department complaining of right flank pain radiating to his groin like his previous episodes of renal colic. He states the pain comes in “waves,” is associated with nausea but no vomiting. On exam, he is afebrile and appears very uncomfortable while grabbing his right flank. He has used ketorolac, acetaminophen and tamsulosin in the past. He really wants to avoid taking any opioids and is wondering if acupuncture could work?

Background: We have covered renal colic a number of times on the SGEM:

* SGEM#4: Getting Un-Stoned (Renal Colic and Alpha Blockers)

* SGEM#32: Stone Me (Fluids and Diuretics for Renal Colic)

* SGEM#71: Like a Rolling Kidney Stone

* SGEM#97: Hippy Hippy Shake – Ultrasound Vs. CT Scan for Diagnosing Renal Colic

* SGEM#154: Here I Go Again, Kidney Stone

* SGEM#202: Lidocaine for Renal Colic?

Here are the SGEM bottom lines on the management of renal colic from those previous episode:

Expulsive therapy is unnecessary for ureteric stones < 5mm.

There is some weak evidence that tamsulosin may help passage of larger stones (5 to 10 mm).

You don’t need to push fluids (oral/IV) or use diuretics to pass kidney stones.

Bedside emergency department ultrasound is safe and has several advantages over CT for the diagnosis of kidney stones.

Lidocaine cannot be recommended for the treatment of renal colic at this time.

We have also covered a couple of acupuncture papers on the SGEM.  Watch for a new episode coming up on battlefield ear acupuncture to treat low back pain in the emergency department.

* SGEM#187: Pin Cushion – Acupuncture in the Emergency Department

* SGEM#211: Pins and Needles – Acupuncture for Migraine Prophylaxis

The summary from those two critical reviews were:

There is no high-quality evidence that acupuncture works for patients presenting to the emergency department with back pain, ankle sprains or migraines.

The study on acupuncture to prevent the re-occurrence of migraine headaches in patients without aura does not provide any evidence of the efficacy.

The authors of the trial we are going to look at today say that acupuncture has been proven have efficacy treatingrenal colic pain.

* Kaymar M et al. Comparison of the efficacy of diclofenac, acupuncture, and acetaminophen in the treatment of renal colic. Am J Emerg Med. 2015;33:749–753.

* Lee YH et al. Acupuncture in the treatment of renal colic. J Urol. 1992;147:16–18.

These were two small non-blinded trials that limit their conclusions of ...

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Date: May 16, 2018

Reference: Freund et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events
 Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA February 2018.

Guest Skeptic: Dr. Jeffrey Kline (@klinelab) is the Vice Chair of Research in Emergency Medicine and a professor of physiology, Indiana University School of Medicine. He is the editor in chief of AEM, creator of Pulmonary Embolism Rule-out Criteria (PERC) Rule and has published extensively in the area of pulmonary emboli. We have even made a Batdoc Video together on pulmonary embolism.

Case: A 47-year-old woman presents to the emergency department with a 24-hour history of chest pain and shortness of breath. She has a past medical history of hypothyroidism and gastroesophageal reflux disease. She is on levo-thyroxine and a proton pump inhibitor. Vital signs are normal (HR 72, BP 130/80, RR 12, O2 Sat 97% and 37.1C) and physical examination does not indicate the cause of her complaint. ECG, chest x-ray and routine lab work is also normal, including a troponin. You risk stratify her by gestalts and Well’s criteria as not high risk and wondering if you can PERC Rule her out and not order a d-dimer.

Background: The Pulmonary Embolism Rule-out Criteria (PERC) Rule is an eight-item clinical decision instrument. The eight-items include the following clinical criteria. If the answer to any of these questions is positive a d-dimer is indicated.

Listen to the podcast on iTunes to hear Dr. Kline discuss some background information on the diagnosing of pulmonary embolism and the PERC Rule.

* The History of the PERC Rule – How did it come about, why eight-items instead of five and when did you publish the first PERC paper?

* The Controversy of its Use in Europe – Why do the Europeans seem not to like the PERC Rule?

* The Power of Gestalt – How does it compare to risk stratifying tools like Well’s Criteria?

* The Inference about Sub-Segmental PE and Possible Over – Diagnosis?

* How to Use PERC Rule and Why this Differs from YEARS?

Clinical Question: Does PERC Rule work in France?

Reference: Freund et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events
 Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA February 2018.

PROPER stands for PERC Rule to Exclude Pulmonary Embolism in the Emergency Department. It was a crossover cluster-randomized clinical non-inferiority trial conducted in France.

* Population: Adult patients presenting to the emergency department with low gestalt clinical probability pulmonary embolism.

* Inclusion: New-onset presence or worsening of shortness of breath or chest pain and a low clinical probability of PE, estimated by the treating physician’s gestalt as an expectation below 15%.

* Exclusion: Obvious etiology to the acute presentation other than PE (eg, pneumothorax or acute coronary syndrome), an acute severe presentation (hypotension, SpO2<90%, respiratory distress), a contraindication to CTPA (impaired renal function with an estimated creatinine clearance <30 mL/min; known allergy to intravenous radio- opaque contrast), pregnancy, inability to be followed up, or if they were receiving any anticoagulant the...

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Date: May 12th, 2018

Reference: Gonin P et al. Excited Delirium: A Systematic Review. AEM May 2018.

Guest Skeptic: Dr. Chris Bond is an emergency physician and clinical lecturer at the University of Calgary. He is currently the host of CAEP Casts, which highlights educational innovations from emergency medicine residency programs across Canada. Chris also has his own #FOAMed blog called Standing on the Corner Minding My Own Business (SOCMOB).

Case: A 24-year-old male is brought into the emergency department by police. He was running around wearing a Batman suit, jumping on cars and screaming he is Batman. He is brought to the emergency department extremely agitated and despite being held down by two police and three security guards he is still trying to bite the staff. You cannot obtain any vital signs and this patient is a danger to himself and staff. How will you manage this patient?

Background: Cases of extreme agitation have been described since the 19thcentury, with Luther Bell’s eponymous “Bell’s mania” being published in the American Journal of Insanity (now American Journal of Psychiatry) in October, 1849 [1]. Bell distinguished these cases of extreme agitation from delirium tremens, diseases of the meninges and advanced typhoid based on a list of clinical criteria, as well as autopsy results from the brains and intestines of the patients.

Bell’s case mortality rate for this condition was approximately 75%, though this was by no means rigorous data analysis. Interestingly, physicians of the day did not think these cases of extreme agitation would benefit from venesection (blood-letting) but did recommend this for the differential diagnoses.

We have covered Alexander Hamilton’s blood-letting experiment from 1816 on camp fever with Dr. Rob Leeper on SGEM#200. The number needed to harm (death) with blood-letting for soldiers with camp fever was four (NNH 4) and therefore we could not recommend blood-letting as a treatment modality for camp fever.

The term excited delirium syndrome (ExDS) was coined in the 1980s, after a flurry of deaths of individuals in custody or during arrests following extremeagitation [2]. ExDS usually involved men in their 30s after cocaine, methamphetamine, or ecstacy abuse [3-5].

These cases were not limited to patients in custody, however, and fatal cases of ExDS appeared in the hospital without any trauma, physical restraint or police intervention [5]. Given the significant morbidity and mortality rate of 8-10%, this syndrome remains of great importance to the emergency provider [6,7].

Over 150 years since it was first described, there is still no standardized definition of ExDS and diagnostic criteria have not been universally recognized. While the American Psychiatric Association and World Health Organization do not recognize this syndrome as a distinct clinical entity, the American College of Emergency Physicians (ACEP) has recognized it since 2009 [7].

The ACEP definition of ExDS includes “acute delirium (not linked to dementia or preexisting pathologies) associated with extreme physical and psychomotor agitation”.The criteria for this diagnosis are inspired by a Canadian police census report [8] and other case descriptions [2, 7, 9]

Clinical Question: What is the definition, epidemiology, pathophysiology and evidence-based management and treatment of excited delirium?

Reference: Gonin P et al. Excited Delirium: A Systematic Review. AEM May 2018.

* Population: Patients with excited delirium

SGEM #194: Highway to the Dexamethasone – For Pediatric Asthma Exacerbations Podcast (escuche el audio): GlobalSGEM-Spanish-194 ¡Hola a todos! Nosotros somos Manrique Umaña y Joselina Seoane, y somos sus anfitriones para este episodio de “La Guía para Escépticos para Medicina de Emergencias o SGEM”. Este es un proyecto de transferencia de conocimientos iniciado en el 2012 por […]

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Date: March 6th, 2018

Reference: White et al. The “Batman Effect”: Improving Perseverance in Young Children. Child Development December 2016.

Guest Skeptic: Dr. Casey Parker is a rural Generalist working in Broome, Australia. He has particular interests in Emergency Care, Aboriginal Health, Paediatrics, Trauma and Women’s Anaesthesia. Casey has this great blog and podcast called Broome Docs. Casey and I made a #Batdoc video at SMACCdub.

Case: It is flu season and there is an endless stream of patients with sniffles, snot and sneezes!  The waiting room is moaning with mildly unwell men; all with ‘the worst cold ever!” 

The residents are working double shifts in order to cover their fallen comrades. They are doing their best to avoid prescribing antibiotics whilst avoiding being coughed upon and writing endless, uninspiring discharge letters to the primary care docs.  It is a Sisyphean task of tremendous tedium.

As the senior doctor in the emergency department you wonder, how can you keep their spirits up and maintain the momentum – we need to maximize perseverance  and limit distraction from the tedium.

Background: Working in the emergency department is very tough. Sometimes it feels like it would take super human strength and skills to finish a shift.

There are comic book super heroes that are physicians. Most people are probably familiar with Marvel’s Dr. Strange. He was a neurosurgeon who had his hands injured in a car accident. In a desperate search to cure his injuries he turns to occult eastern mysticism. Soranik Natu is also a neurosurgeon, daughter of Sinestro and a member of the Green Lanter Corp. Thor the god of thunder was transformed into a physician named Donald Blake in the earlier comic book series?

* Batman Fun Facts:

* Bruce Wayne, Batman’s secret identity, came from two historical figures (Robert the Bruce, a Scottish national hero and Mad Anthony Wayne, a hero of the American Revolution)

* There was a Batman course taught at the University of Victoria in Canada called the Science of Batman

* Andy Warhol directed the first-ever Batman movie in 1964 but it was made without the consent of DC Comics.

Clinical Question: Does self-distancing by dressing up as Batman enhance perseverance at a tedious task? 

Reference: White et al. The “Batman Effect”: Improving Perseverance in Young Children. Child Development December 2016.

* Population: Typically developing four- and six-year-old children from the Minneapolis area

* Exclusions: None listed

* Intervention: Impersonating an exemplar other (such as Batman) while doing a repetitive task for 10 minutes. They would be asked is Batman working hard?

* Repetitive Task: The task was a simple go/no-go slow process computerized task. The children were told the task was very important and it would be helpful if they worked hard on it as long as they could. They were also told they could take a break by playing an extremely attractive video game.

* Exemplar Other: Besides Batman, they could also dress up as Bob the Builder, Rapunzel or Dora the Explorer but the choice was obvious.

* Control: Same repetitive task but asked if they were working hard from a third person perspective (is Casey working hard) or a first-person perspective (am I working hard)?

* Outcome:

* Primary: Percentage of time spent on the assigned task

* Secondary: Effect of age (4 vs. 6 controlled for gender), Theory of Mind [1], executive function, forward and backward digit span [2], dimensional change cart sort [3],

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Date: April 25th, 2018

Reference: Stern A et al, Corticosteroids for pneumonia (Review). Cochrane Database of Systematic Reviews. December 2017.

Guest Skeptic: Dr. Jake Turner, a foundation doctor working in the UK.

Case: A 72-year-old gentleman presents to your emergency department. He has been generally unwell for around one week, with a worsening cough, shortness of breath and fever. He is now feeling extremely short of breath, appears confused and is pyrexial at 39 degrees centigrade. His observations are heart rate of 102 beats per minute, respiratory rate of 34 breaths per minute, blood pressure of 110/67 mmHg, and oxygen saturation of 91% on room air.

Background: There have been a large number of trials on steroids for a variety of conditions in the last year and we have covered some of them on the SGEM:

* The ADRENAL trial on steroids in septic shock demonstrating no all-cause mortality benefit at 90 days (SGEM#208).

* Oral prednisolone in preschool children with virus-associated wheeze showed a decrease in emergency department length-of-stay with steroids compared to placebo (SGEM#206).

* Corticosteroids for sore throats seem to provide some modest benefit (SGEM#203).

* A single dose of dexamethasone was non-inferior to a three-day course of oral prednisolone in the treatment of children with an acute asthma exacerbation (SGEM#194).

The Cochrane collaboration has come out with yet another paper on our favourite panacea, the steroid. This time, it is a systematic review and meta-analysis looking at the effects of steroids in patients presenting with a community acquired pneumonia.

This is an update from their previous review on the topic published in 2011. It showed that in most patients with pneumonia, corticosteroids are beneficial for accelerating the time to resolution of symptoms, but lacked enough data to make any recommendations.

* “In most patients with pneumonia, corticosteroids are generally beneficial for accelerating the time to resolution of symptoms. However, evidence from the included studies was not strong enough to make any recommendations.” [1]

Clinical Question: Do steroids safely reduce morbidity and mortality in patients with community acquired pneumonia?

Reference: Stern A et al, Corticosteroids for pneumonia (Review). Cochrane Database of Systematic Reviews. December 2017.

* Population: Adults and or children presenting to the emergency department or primary care settings with a diagnosis of community acquired pneumonia confirmed radiographically.

* Exclusions: Studies including only neonates, patients with Pneumocystis pneumonia, and patients with HIV.

* Intervention: Systemic corticosteroids given at any dose, by any mode and for any duration. Steroids that were included were: prednisone, prednisolone, methylprednisolone, betamethasone, dexamethasone, triamcinolone, and hydrocortisone.

* Comparison: Placebo or no corticosteroids.

* Outcome:

* Primary Outcome: All-cause mortality at 30 days after randomization. If 30-day mortality not reported then the outcome closest to 30-days was used.

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Date: April 12th, 2018

Reference: Ohle R et al. Clinical Examination for Acute Aortic Dissection: A Systematic Review and Meta-analysis. AEM April 2018

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine (AEM).

Case: You are in the emergency department caring for a 65-year-old man with sharp chest pain radiating to the back. Blood pressure is elevated, and his pain was sudden in onset. His chest x-ray is normal, and there is no sign of asymmetric pulses. The EKG and laboratory tests are normal. You are wondering if you need to order a CT to rule out an aortic dissection.

Background: Aortic dissection is a rare but deadly disease which can confound the emergency physician’s diagnostic abilities. Some estimates are that up to 38% of cases are initially missed [1]. Mortality is up to 40% in the acute phase [2] , and 70% by two weeks [3].

The most common feature of aortic dissection is pain, in the chest, back, and/or abdomen, but with aortic dissection being so rare and pain being so prevalent a complaint, diagnosing aortic dissection becomes difficult. Data is lacking on predictive value of clinical features; much of the prior literature focuses on patients already diagnosed with aortic dissection.

There are two clinical prediction tools for the diagnosis of aortic dissection. One is from the American Heart Association called the aortic dissection detection (ADD) risk score. Our good friend over at REBEL EM, Salim Rezaie put together a nice table showing the score that we will include in the show notes. If any one of the predisposing conditions, pain features or physical exam findings are positive you add one point to the score.

The other is a simpler three-variable rule called the Von Kodolitsch score. This tool includes aortic pain (immediate-onset tearing or ripping pain), mediastinal/aortic widening on chest x-ray, or pulse/BP differential.

American College of Emergency Physicians (ACEP) published a guideline in 2015 for the diagnosis of acute aortic dissection. ACEP gives level C recommendations for the use of existing clinical decision tools:

* “In an attempt to identify patients at very low risk for acute non-traumatic thoracic aortic dissection, do not use existing clinical decision rules alone. The decision to pursue further workup for acute non-traumatic aortic dissection should be at the discretion of the treating physician.” [4]

Clinical Question: What is the diagnostic accuracy in aortic dissection of various clinical features (history and physical), imaging tests and clinical decision instruments?

Reference: Ohle R et al. Clinical Examination for Acute Aortic Dissection: A Systematic Review and Meta-analysis. AEM April 2018

* Population: Adult patients presenting to the emergency department with suspected acute aortic dissection in whom testing, criterion standard, and results of testing were available,

* Intervention: This was a review of diagnostic accuracy in aortic dissection, so no interventions were performed.

* Comparison: None

* Outcome: Diagnostic accuracy of various tests, features of aortic dissection and clinical decision instruments (sensitivity, specificity and likelihood ratios).

This is an SGEMHOP episode. We are pleased to welcome the lead author of this SRMA, Dr. Robert Ohle. Robert is a practicing emergency medicine physician and Director of Research for emergency medicine at Health Science North in Sudbury, Ontario. His research program focuses on improving recognition and...

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Date: April 13th, 2018

Reference: Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet 2017

Guest Skeptic: Dr. Nick Papalia completed his MD at Western University. He is currently completing his third year of Obstetrics and Gynecology residency at the University of Calgary.

Case: 37-year-old primiparous woman has a spontaneous vaginal delivery following an induction of labour at 39 weeks for gestational diabetes for which she is treated with insulin. She delivered a vigorous 3800g boy following a brief episode of shoulder dystocia. She is otherwise healthy but does have a remote history of asthma. Aside from insulin and prenatal vitamins, she takes no medications.

Approximately five minutes after delivery of the placenta, as you are evaluating her perineum, she begins to have a moderate amount of vaginal bleeding. Her nurse performs fundal massage which temporarily improves her flow.

Background: Utako and Shosuke Okamoto discovered TXA in the 1950’s while searching for a treatment for postpartum hemorrhage [1].  TXA is a synthetic analog of the amino acid lysine. The normal process is for plasminogen to breakdown fibrin and prevent blood clots. TXA acts as an antifibrinolytic agent. It binds to lysine receptor sites on plasminogen blocking its action on fibrin. The ultimate result is the fibrin matrix structure is maintained and bleeding is reduced.

Post-partum hemorrhage (PPH) is defined by the World Health Organization (WHO) as:

* “a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process”. PPH is one of the leading causes of maternal mortality around the world [2].

We have covered the use of TXA for trauma (CRASH-2) with Dr. Anand Swaminathan. This trial showed TXA is safe and effective treatment in patients with hemorrhagic shock from trauma in reducing mortality.  We also did a couple of podcasts on TXA being effective for epistaxis (SGEM#210 and SGEM#53).

The American College of Obstetricians and Gynecologists (ACOG) published guidelines for the management of postpartum hemorrhage including the use of TXA. They give TXA a Level B recommendation (based on limited or inconsistent scientific evidence): [3]

* “Given the mortality reduction findings, tranexamic acid should be considered in the setting of obstetric hemorrhage when initial medical therapy fails.”

There was also a commentary published in the issue of Obstetrics and Gynecology by Pacheco et al. [4] They concluded that TXA appeared to be a safe and effective option in the treatment of post-partum hemorrhage. Their recommendation is as follows:

* “In established postpartum hemorrhage, may administer 1 g intravenously within 3 hours of birth. If required, may administer a second dose within the next 24 hours. The half-life of TXA is 2 hours and its antifibrinolytic effect lasts for up to 7–8 hours in serum. A single dose should suffice in most cases.
”

We checked to see if the Society of Obstetricians and Gynaecologists of Canada (SOGC) and could not find any practice guidelines on TXA for PPH. The latest guidelines from the SOGC on PPH was published in 2009 [5].

Clinical Question: Does TXA improve survival in women with post-partum hemorrhage?

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Date: March 23rd, 2018

This is a SGEM Xtra book review. I had the pleasure of interviewing Jeanne Lenzer. She is an award-winning independent medical investigative journalist who has written for the BMJ. Jeanne has also written for the Atlantic, the New York Times Magazine, Mother Jones, Huffington Post and Slate.

Jeanne book is called The Danger Within Us: America’s Untested, Unregulated Medical Device Industry and One Man’s Battle to Survive It. In the book, she takes a critical look at the medical device industry.

One of the main inspiration for her book is the Legend of Emergency Medicine Dr. Jerome Hoffman. He is also one of my mentors who taught me to be skeptical of the medical literature.

Listen to the podcast on iTunes as Jeanne describes some of the problems with the medical device industry. Some of the disturbing facts she provides include:

* Medical interventions have become the third leading cause of death in America.

* The FDA does not require clinical testing for most high-risk implanted devices.

* The death rate caused by medical devices is unknown, because no one is keeping track.

Jeanne provides some of examples of patients who experienced significant harm instead of benefit with implantable medical devices like a vagus nerve stimulator or metal on metal artificial hip. We also discuss some of the possible solutions to the medical device industry and mention some additional resources: Choosing Wisely, Lown Institute, Right Care Alliance, ClinicalTrials.gov, John Ioannidis, and James McCormick.

Let me know if you like this type of SGEM Xtra and if the responses are positive I will consider doing more book reviews.

The SGEM will be back next week with a structured critical review of a recent publication trying to cut the knowledge translation window down from over ten years to less than one year.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

 

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Date: March 30th, 2018

Reference: Bronzetti et al. Upside-down position for the out of hospital management of children with supraventricular tachycardia.  International Journal of Cardiology. February 2018.

Guest Skeptic: Dr. Robert Edmonds is an Emergency physician in the US Air Force. This is his 6th visit to the SGEM.

DISCLAIMER: The views and opinions of this podcast do not represent the United States Government or the US Air Force.

Case: A seven-year-old girl presents to your emergency department complaining of palpitations.  On exam she appears anxious and begs you not to give “that drug that makes my heart stop like that last doctor did.”  You know vagal maneuvers are first-line, but there’s variation in techniques.  As the patient already tried breathing out of her clenched nose, you wonder if there is another safe method you can try prior to medications.

Background: Supraventricular tachycardia (SVT) has a prevalence anywhere from 1 in 250 to 1 in 1,000 in children and is the most common arrhythmia in children. Forty percent of patients experience the first episode of SVT in the first month of life, and over 50% have their first episode in their first year of life [1].

Vagal maneuvers are thought to be first-line treatment as they are non-invasive and can rapidly resolve the episode when successful.  Several methods exist, such as carotid sinus massage, mammalian dive reflex, and the Valsalva maneuver [2].

We have covered SVT on the SGEM a couple of times. The first time was a Cochrane systematic review done by Smith et al on the effectiveness of the Valsalva maneuver for reversion of SVT (SGEM#67). Only one study in that review was from the emergency department and it reported a reversion rate of 19%.

The second time we covered SVT was a critical review of the REVERT Trial (SGEM#147). It was an randomized control trial using a modified Valsalva maneurer to convert SVT. The result was a return to sinus rhythm at one minute in 43% of patients treated with the modified Valsalva vs. 17% of patients treated with the standard Valsalva.

This gives an NNT of 4. Four patients needed to be treated with the modified Valsalva for one more patients to return to sinus rhythm at one minute.  The authors of the study we are talking about today were aware of case studies of a modification to the Valsalva maneuver in children [3-5]. The maneuver involves the child doing a handstand or being held upside down. 

Clinical Question: Is the upside-down position a safe and effective modified Valsalva maneuver?

Reference: Bronzetti et al. Upside-down position for the out of hospital management of children with supraventricular tachycardia.  International Journal of Cardiology. February 2018.

* Population: Patients age 1-18 years followed at the pediatric arrhythmology outpatient clinic with SVT. SVT was defined by a regular, narrow complex tachycardia with QRS duration <0.12 s on ECG and/or for the demonstrated sensitivity to adenosine diagnosed by a pediatric cardiologist with >15 years of experience in pediatric arrhythmia management.

* Exclusion Criteria:

* Age – Greater than 18 years or  less than one year

* Unstable – Patients with hypotension or those who required immediate cardioversion

* ECG diagnosis of automatic atrial tachycardia, permanent form of junctional reciprocating tachycardia, atrial fibrillation or flutter

* Underlying congenital heart disease