Hello Modified Valsalva Maneuver. Good-Bye Ice. Adenosine, Take a Backseat.

003-Modified-Valsalva

Chief Complaint

Pt comes in with a heart rate of 170-200. Complains of palpitations/sob/chest pain/dizziness/or nothing.  Is this SVT or A-Fib? Hint! Today we are talking about SVT.

Bedside Checklist

  • Take off clothing waist up. Put on a hospital gown.
  • Immediately place pulse ox, leads, and bp cuff – in that order.
  • If oxygenation is poor with good waveform – address this first. Start with a nasal cannula, if that doesn’t give your pt relief. Apply NRM, while you set up BIPAP. Find out if they have COPD or emphysema or a chronic smoker – oxygen saturation requirements are less for this population. High flow nasal cannula may be an option.
  • Keep hob elevated to min. 30 degrees. 45-90 better.
  • Watch the position that your patient is sitting.
  • If they are leaning forward or sitting up straight – Put the hob at 90 degeees and ask them, is it easier for you to breathe sitting up.
    • Obese patients may prefer to have legs over the side of the stretcher due to abdominal girth.
  • Get an EKG stat. After you get the 12 lead – keep the EKG leads on pt
  • Is this an atrial or ventricular rhythm? Today it’s an atrial rhythm. It’s so fast, we don’t know if it’s SVT or A Fib!
  • Get 1-2 iv access. Preferably 2.
  • Labs now or later? This is controversial.
    • If the pt looks like they are a hard stick, I get labs so I can at least run a venous panel to get a baseline pCO2 level. If the pt goes on BIPAP or high flow nasal cannula – you can trend this along with other values to direct the oxygen needs.
    • Look at your pt. If they are talking to you and appear somewhat calm – you have the time to get labs off that first iv line.
    • If the pt looks really bad, just get the iv access and you can get the labs later.
    • Ideally you have a 2nd nurse who is putting in the IV line while the EKG is in progress so you can get the labs right away.

While you are doing this – examine your patient:

  • Mental status – hello sir! Can you tell me your name? Do you know where you are? What day is it? If you know the pt has dementia, what year or who’s the president seems to work better.
  • Work of breath – are they gasping for air? What is the respiratory rate? Do they look tired? – worried about losing compensatory drive?
  • Auscultate the lungs. Wheezing – inspiratory or expiratory or both? Upper or throughout the lungs? Crackles? Decreased air movement? Trick question – are they coming in with multiple problems? Yes, sometimes that happens.

Get the story as the above is happening:

  • What happened? When did this happen? Were you sitting, walking, lying down?
  • SOB/Chest pain/Palpitations/Dizziness or Lightheadedness/Nausea/Vomiting/LOC?
  • If BIBEMS, Ask EMS how did they find the patient and where, what interventions (oxygen, iv line, meds), do they look better now?
  • Has this ever happened to you before?
  • Any fevers or recent illness?
  • Do you have a pacemaker or defibrillator?
  • What medications are you on?
  • Do you have any allergies to medications?

SVT Treatment

First line of treatment: Vagal Maneuvers.
  • Ice to face
  • Carotid massage
  • Tell the pt to bear down
  • Modified Valsalva Maneuver Technique
Second line of treatment: Adenosine
In 2015 the Lancet published the REVERT trial and the findings were pretty impressive. The REVERT trial created another vagal maneuver that actually works!  It’s called a Modified Valsalva Maneuver Technique.  I’ve tried this out myself and it works pretty well. You just have to make sure your technique is good and you have 2 people at the bedside.

Modified Valsalva Maneuver Technique:

  • Have the pt sit down on the stretcher with HOB elevated at 45 degrees (semi-recumbent) or the pt can just sit up straight.
  • Use a 10mL syringe (pressure of 40mmHg) and have them blow into it for 15 seconds (creating the Valsalva strain)
  • Immediately afterwards, place the pt in a supine position and passive leg raise 45-90 degrees for 45 seconds. (Increases the relaxation phase of venous return and vagal stimulation). This is the modification.
  • Technique can be repeated once before adenosine is used.
Repeat EKG
Something I have come across is that we would do this technique and it would slow the rhythm down but it turns out it is A-Fib or A-Flutter in origin. If that’s the case, no need to repeat but at least you know what the underlying rhythm is and treat accordingly.

Why I love this?

  • You can give your patients a 10mL syringe and they can convert at home.
  • It’s cheap.
  • I don’t have to give adenosine.
  • Most of all, the conversion rate is 43% versus 17% using a standard Valsalva maneuver

Eligible SVT (supraventricular tachycardia)

  • Re-entrant, atrial tachycardia, other
  • Undetermined narrow complex tachycardia

Ineligible Rhythms

  • Atrial Flutter
  • Atrial Fibrillation
  • Broad Complex Tachycardia
  • Sinus Tachycardia
References:

Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet, 2015

Video of the Modified Valsalva Maneuver. Lancet, 2015

REVERT – The Modified Valsalva Maneuver by Ben Cleary, MD. For those who want the cliff notes version of the article.

2 thoughts on “Hello Modified Valsalva Maneuver. Good-Bye Ice. Adenosine, Take a Backseat.

  1. Great point! I’m also curious about how this may translate into the Peds population. I wonder if it may be a case to case basis on the maturity of the younger child…Just like how some kids are able to suck their medicine through the syringe “all by themselves!” But I agree, there are other factors and variables that are Peds-specific and may not work. Anyone out there tried the modified valsalva maneuver on pediatrics with success? What age group?

  2. Hola Hola, great topic to cover ! The modified maneuver seems to be a great alternative to traditional valsalva techniques. As a Peds ED Nurse, I am curious though as to how this maneuver might translate into the treatment of Pediatric SVT, which is quite common. Seems the REVERT RCT and another trial by Walker et al, Emerg. Med J, 2010 both excluded pediatric populations from the study. Granted tidal volume and forced expiratory volume may not be sufficient in the younger pediatric age groups, to perform the maneuver, but it seems it may be of great help. Will pass the study along. Thanks 🙂