Modified Positional Valsalva more successful than traditional Valsalva maneuver
Carotid sinus massage for 15 seconds )
Auscultate for bruits prior to performing
Massage one side at a time
Do not attempt in elderly patients or patients with known carotid artery disease or risk factors
Mammalian diving reflex (pediatrics)
Most effective in infants
Apply cold ice pack over face for 15-30 seconds, covering nose
Be conscientious of infants as obligate nasal breathers
Auscultate for bruits prior to performing
Massage one side at a time
Do not attempt in elderly patients or patients with known carotid artery disease or risk factors
Most effective in infants
Be conscientious of infants as obligate nasal breathers
Adults:
6mg rapid IV push (1st dose)
Ensure rapid push is through a large bore IV with proximity to the heart (left side antecubital preferred) as half-life of adenosine is less than 10 seconds 
Follow rapid push with 20cc rapid saline flush, consider Y-tubing.
Raise left arm above head immediately after push to facilitate rapid delivery to myocardium
If unsuccessful, push 12 mg (2nd dose)
If 2nd dose unsuccessful, consider calcium channel blocker as below
May have higher conversion rates and patient comfort in appropriate patients
Pediatrics:
0.1mg/kg (1st dose) rapid IV push as above
If unsuccessful, attempt second 0.1 mg/kg dose or escalate immediately to 0.2mg/kg (2nd dose) IV push
Relatively contraindicated in asthmatics due to increased bronchoconstriction
Some literature to support 3rd dose of 18mg if 12mg fails
Patients taking methylxanthines (eg caffeine, theophylline) may require higher dose
Consider initial adult dose of 3mg, if:
Central line
Decreased transit time to heart
Heart transplant
Relative sensitivity of denervated transplanted hearts
Note that full dose may be used safely, but initial half-dose is reasonable 
Taking carbamazepine or dipyridamole
6mg rapid IV push (1st dose)
Ensure rapid push is through a large bore IV with proximity to the heart (left side antecubital preferred) as half-life of adenosine is less than 10 seconds 
Follow rapid push with 20cc rapid saline flush, consider Y-tubing.
Raise left arm above head immediately after push to facilitate rapid delivery to myocardium
If unsuccessful, push 12 mg (2nd dose)
If 2nd dose unsuccessful, consider calcium channel blocker as below
May have higher conversion rates and patient comfort in appropriate patients
Ensure rapid push is through a large bore IV with proximity to the heart (left side antecubital preferred) as half-life of adenosine is less than 10 seconds 
Follow rapid push with 20cc rapid saline flush, consider Y-tubing.
Raise left arm above head immediately after push to facilitate rapid delivery to myocardium
May have higher conversion rates and patient comfort in appropriate patients
0.1mg/kg (1st dose) rapid IV push as above
If unsuccessful, attempt second 0.1 mg/kg dose or escalate immediately to 0.2mg/kg (2nd dose) IV push
Central line
Decreased transit time to heart
Heart transplant
Relative sensitivity of denervated transplanted hearts
Note that full dose may be used safely, but initial half-dose is reasonable 
Taking carbamazepine or dipyridamole
Decreased transit time to heart
Relative sensitivity of denervated transplanted hearts
Note that full dose may be used safely, but initial half-dose is reasonable 
Note that full dose may be used safely, but initial half-dose is reasonable 
Diltiazem 0.25mg/kg IV over 2min
May give 0.35mg/kg IV if inadequate response after 15min
If IV bolus worked start IV infusion at 5–20mg/hr
A slow infusion of 2.5 mg/min to a maximum of 50 mg is also an option
In this trial 50% had converted by 12 mg and 75% had converted by 18 mg
Contraindications: Hypotension, CHF, any suspicion of VT
Consider calcium gluconate premedication OR afterwards if BP falls
Phase 2 trial completed on intranasal CCB (Etripamil)
High conversion rate (65 to 95%)
Median time to conversion 3 minutes
May give 0.35mg/kg IV if inadequate response after 15min
If IV bolus worked start IV infusion at 5–20mg/hr
A slow infusion of 2.5 mg/min to a maximum of 50 mg is also an option
In this trial 50% had converted by 12 mg and 75% had converted by 18 mg
Contraindications: Hypotension, CHF, any suspicion of VT
Consider calcium gluconate premedication OR afterwards if BP falls
In this trial 50% had converted by 12 mg and 75% had converted by 18 mg
High conversion rate (65 to 95%)
Median time to conversion 3 minutes
Verapamil 1-4 mg/kg q8hrs (only if >12 months old)
May cause significant hypotension in infants
Metoprolol 5mg IV q5min x 3; give 50mg PO if IVP effective
Esmolol 500mcg/kg IV over 60sec
May give repeat bolus if inadequate response after 2-5min
If effective start infusion at 50mcg/kg/min (titrate up to 300mcg/kg/min)
May give repeat bolus if inadequate response after 2-5min
If effective start infusion at 50mcg/kg/min (titrate up to 300mcg/kg/min)
Propranolol 0.3-1mg/kg q6hrs IV (contraindicated in asthmatics)
Atenolol 0.5-1mg/kg q12hrs (caution in asthmatics)
Paroxysmal supraventricular tachycardia
Regular
Wandering atrial pacemaker
AV Node Independent
Wide-complex tachycardia
Sinus tachycardia
Nonsustained ventricular tachycardia
Atrial tachycardia 