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I was impressed to learn the success of vagal maneuvers. They always seemed like something worth trying while waiting for the nurse to draw up meds, and I’ve had a few patients (and an EM colleague with periodic SVT episodes) swear by these techniques. But our readers want evidence, and here it is:
Vagal Maneuvers (ACC/AHA Class I recommendation for reentry SVT, Level of Evidence B)
Massage of the carotid sinus, having the patient valsalva, and cold-water facial immersion have all been used with varying success in the treatment of SVT. In a controlled clinical trial of 148 patients, carotid sinus massage, valsalva maneuver, or the combination of carotid sinus massage and valsalva maneuver were successful in terminating nearly 30% of SVTs.71 A comparison of these techniques for termination of AVRT and AVNRT found that the valsalva maneuver in the supine position was the most effective, with 54% of SVTs successfully treated by this method. Termination rates were lower with carotid sinus massage (22%) and cold-water facial immersion (17%).72
It has been suggested that vagal maneuvers are most likely to be successful in terminating the SVT if initiated soon after the arrhythmia starts.73 Sympathetic tone often increases with prolonged duration of the tachydysrhythmias, rendering vagal maneuvers less effective. Patients should be educated regarding vagotonic methods and instructed to use these methods at the onset of symptoms.
With an important caveat from the Risk Management section –
8. “It was a regular narrow complex tachycardia on the monitor and I couldn’t see any P waves. While the nurse was pulling adenosine, I figured it couldn’t hurt to try carotid sinus massage.” Do no harm – even a simple vagal maneuver like carotid sinus massage can be disastrous in patients with a history of CVA or presence of a carotid bruit on examination. To avoid neurologic complications, it’s imperative to get a quick medical history and listen for carotid bruit before initiating carotid sinus massage. If you want to try a vagal maneuver, ask the patient to valsalva.
71. Lim SH, Anantharaman V, Teo WS, et al. Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Intern Med. Jan 1998;31(1):30-35. (Prospective; randomized case study; 148 episodes SVT)
72. Mehta D, Ward DE, Wafa S, et al. Relative Efficacy of Various Physical Maneuvers in the Termination of Junctional Tachycardia. Lancet. May 1988;1(8596):1181-1185. (Prospective; 35 patients)
73. Ferguson JD, DiMarco JP. Contemporary management of paroxysmal supraventricular tachycardia. Circulation. Mar 2003;107(8):1096-1099. (Review)
Excerpts above from Singh A, Carnell, J. An Evidence-Based Approach To Supraventricular Tachydysrhythmias. Emergency Medicine Practice. 2008;10.
May 2, 2008 at 9:14 am |
I recently tried all the vagal moves; including cold water immersion. The patient was young and was willing to try anything. After the cold water dunking, her SVT didn’t break, but she said she felt more awake!