Modified Valsalva for SVT- anyone actually have it work consistently?

[Zebra Hunter]

I was having this conversation with a partner a couple days ago and I figured I'd discuss it here. I've utilized this maneuver for every single SVT patient (outside of the extremes of age and girth) I've seen since the initial study was published 4 years ago. I have yet to have it work. I am currently probably somewhere around 0 for 50+. I'm sure some will probably say I'm doing it wrong, but I have watched the video from the individuals that developed the maneuver numerous times and can confidently say that I am not doing it wrong, it just doesn't work, or doesn't work on my specific patient population. I remember having this discussion in conference during residency. I polled my fellow residents and attendings regarding their success. Several, like myself, had never seen it work, and not a single one had it work more than 1 or 2 times ever. My partner I was discussing this with said he had only seen it work once. I actually once watched a patient convert to sinus after screaming during IV placement about 2 minutes after my modified valsalva failed. That was the only time I've actually ever seen a "vagal maneuver" work.

The issue I have a hard time believing is that not only did the original study find the modified valsalva to work better than traditional vagal maneuvers, they found that it worked an amazing 40% of the time with about 20% in the control group converting to sinus. That is nearly a coin flip for its success. Maybe my patient population is smart enough to attempt vagal maneuvers at home prior to presenting to the ER and that skews my experience to individuals with refractory SVT or maybe they are more prone to refractory SVT. I have no clue, but was wondering if anyone here has actually seen it work consistently?

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[GonnaBeADoc2222]

I have had it work once. I don't waste my time with it anymore. Straight to the adenosine!

 

[GeneralVeers]

I have had it work once. I don't waste my time with it anymore. Straight to the adenosine!

I've had it work once. Was pretty cool that time. I have every patient try to valsalva at the same time the nurse is getting the adenosine.

 

[alpinism]

I've got a roughly 10% success rate.

What I've found is that its not that you're not doing it right its that the patient's not doing it right. Usually its because they're not blowing hard enough activate the vagal reflex. Essentially blowing as hard as possible into the syringe for at least 10 seconds for it to work. Most patient's aren't physically able to do this with the exception of young healthy patents.

 

[RoyBasch]

This mirrors my experience, I've never had it work. I'm always surprised at the people who tell me it works 50-100% of the time. Certainly patient effort may be contributing, and a lot of patients aren't healthy or strong enough to volitionally valsalva themselves. That being said, I had a patient who valsalved himself so hard he got bilateral subconjunctival hemorrhages...still didn't work. Converted with 6mg of adenosine IVP.

 

[deleted859535]

I've had it work once. Was pretty cool that time. I have every patient try to valsalva at the same time the nurse is getting the adenosine.

Same. Worked once for me. Have had a couple conversions with traditional Valsalva as well. I attempt only as long as it takes to get the adenosine and pads on.

 

[MechEDoc]

Yes. Then the patient had 10 second sinus pause before going into a sinus rhythm. Nearly crapped myself until that first p-wave showed up. She really gave it a good go and managed to suppress SA activity for longer than I was expecting.

 

[deleted245139]

I've had it work once. Was pretty cool that time. I have every patient try to valsalva at the same time the nurse is getting the adenosine.

Same here. 0-for-all tries, but I figure hell, why not give it a shot. Grab the meds while we try

 

[Druggernaut]

It never worked for me until I started taking it a step further and put the patient in as extreme Trendelenburg as I can without them sliding off the bed immediately after they're done blowing in the syringe. I think it's 4/4 since I changed to that from just having them lie flat, where I never had success.

 

[WildcatS11]

Worked perfectly for me last night actually. Maybe a few other times as well, but no where near a majority of cases.

 

[TooMuchResearch]

Not really, I typically go straight to diltiazem.

 

[thegenius]

Yup. I forgo adenosine. I use diltiazem 15-20 mg IV slow push over 3 mins or so. The nurse sits there and does charting and pushes a little every 20 seconds.

If the BP is high, which it almost never is, it’s just straight push.

If BP is low like 85/55 and they don’t need to be electrically cardioverted, then I push phenylephrine 200 mcg.

 

[thegenius]

I find that adenosine only works maybe 60-70% of the time. It’s kind of an annoying drug IMO.

 

[deleted547339]

I’m convinced valsalva is the Latin word for “game to play while the nurse draws up adenosine”

 

[TooMuchResearch]

Yup. I forgo adenosine. I use diltiazem 15-20 mg IV slow push over 3 mins or so. The nurse sits there and does charting and pushes a little every 20 seconds.

If the BP is high, which it almost never is, it’s just straight push.

If BP is low like 85/55 and they don’t need to be electrically cardioverted, then I push phenylephrine 200 mcg.

I'll do 20-25 mg over 10 minutes, they just run it on a pump then shut it off once the patient converts.
The phenylephrine is a good thought, I usually just do a fluid bolus.

 

[GonnaBeADoc2222]

I find that adenosine only works maybe 60-70% of the time. It’s kind of an annoying drug IMO.

Is your stock expired or something? I feel like I have 100% success with adenosine.

 

[Groove]

I was having this conversation with a partner a couple days ago and I figured I'd discuss it here. I've utilized this maneuver for every single SVT patient (outside of the extremes of age and girth) I've seen since the initial study was published 4 years ago. I have yet to have it work. I am currently probably somewhere around 0 for 50+. I'm sure some will probably say I'm doing it wrong, but I have watched the video from the individuals that developed the maneuver numerous times and can confidently say that I am not doing it wrong, it just doesn't work, or doesn't work on my specific patient population. I remember having this discussion in conference during residency. I polled my fellow residents and attendings regarding their success. Several, like myself, had never seen it work, and not a single one had it work more than 1 or 2 times ever. My partner I was discussing this with said he had only seen it work once. I actually once watched a patient convert to sinus after screaming during IV placement about 2 minutes after my modified valsalva failed. That was the only time I've actually ever seen a "vagal maneuver" work.

The issue I have a hard time believing is that not only did the original study find the modified valsalva to work better than traditional vagal maneuvers, they found that it worked an amazing 40% of the time with about 20% in the control group converting to sinus. That is nearly a coin flip for its success. Maybe my patient population is smart enough to attempt vagal maneuvers at home prior to presenting to the ER and that skews my experience to individuals with refractory SVT or maybe they are more prone to refractory SVT. I have no clue, but was wondering if anyone here has actually seen it work consistently?

I do both REVERT method and good ol carotid massage while I draw up adenosine. Like you, I don't find that it works very often. Maybe 20% of the time. Anecdotally, the effectiveness seems directly related to the pt's effort.

It works just often enough to keep me superstitious to the point that I keep using it.

 

[dchristismi]

It's worked for me, but I don't bother with the "blow in a syringe" part. I make them bear down as hard as they can, and get their legs very high up afterwards. Patient effort definitely plays a role, and again, I use it because it works some of the time... while the nurse is getting the adenosine.

 

[WildEMDoc]

I've also had great experiences with it, especially in young and otherwise healthy. I'd estimate at least 50% have come out with just modified valsalva.

 

[BoardingDoc]

Hate it. Have a maybe 10% success rate at best. Now I just go straight to adenosine. Works 95% of the time.

 

[thegenius]

Is your stock expired or something? I feel like I have 100% success with adenosine.

no it usually has to do with the IV line they put i think.
First 6 mg doesn't have great success for me, 12 mg usually has better success.

There is so much riga-ma-role around SVT in the ED. If their BP is OK and the pt is comfortable, nurses still flip out.
"Get the adenosine NOW!!!!!!!"

Just give them a nodal blocker and see the next patient, and come back in 10 minutes to see if they converted. If not, give them another dose of the nodal blocker.

No biggie

 

[deleted109597]

Diltiazem is actually more effective at 1 hour than adenosine.
I've never had a patient that's had adenosine ask for it again. They all hate it. One asked me to shock him while awake instead of getting it. I'm telling you, patients hate that feeling of death. It's well reported in the literature.
If they have low BP to begin with, a little neo isn't a bad trick. If they get hypotensive while giving the cardizem, then give calcium. It will stop the peripheral vasodilation without affecting the rate control.
If they're that hypotensive, ACLS recommends shock to begin with. Electricity works really, really well.

 

[HJOvens]

As a student I was taught how to do vagal maneuvers by a cardiac arrythmia specialist. I've used the technique I was taught for 37 years and taught it to many others and overall, I estimate my success rate at 60-75%. Just last week I successively converted an SVT for a colleague who had "tried everything" and failed and was about to move to drugs. The key is to keep in mind two principles;

1. Vagal maneuvers are additive.
2. The strain phase of Valsalva is SYMPTHOMIMETIC - it's the release phase that is vagal in effect.

When you strain - exhale against a closed glottis as in having a bowel movement or a baby - your face turns red. That is because venous blood is held up outside the thorax due to high intrathoracic pressure. Your central vasculature empties and your body thinks it's in shock and heart rate and BP go up. Then, when you release, the waiting blood floods into the chest and your central veins/right heart stretch, sending vagal signals to reduce heart rate and BP.

So, the approach I use is;

1. Place the patient in significant head down/legs up Trendelenburg position.
2. Ask the patient to take a deep breath, and push down hard for your count of 8, demonstrate how to make their face red, and position your fingers over the carotid pulse in the neck.
3. Count to 8 slowly, ensure the patients face and neck veins engorge, then say "release" and simultaneously compress the carotid sinue firmly with your index and middle fingers for several seconds, all while looking at the monitor.

If you've done it right, their heart rate will slow, and either break to sinus, or show you underlying fibrillation or flutter. If the heart rate does not change, I repeat it ONCE then move to drug treatment (or shock).

Good luck!

Howard Ovens [email protected]

 

[WildcatS11]

Diltiazem is actually more effective at 1 hour than adenosine.
I've never had a patient that's had adenosine ask for it again. They all hate it. One asked me to shock him while awake instead of getting it. I'm telling you, patients hate that feeling of death. It's well reported in the literature.
If they have low BP to begin with, a little neo isn't a bad trick. If they get hypotensive while giving the cardizem, then give calcium. It will stop the peripheral vasodilation without affecting the rate control.
If they're that hypotensive, ACLS recommends shock to begin with. Electricity works really, really well.

This seems a little hand-wavey. Any (non anecdotal) source/evidence for this?

 

[deleted859535]

This seems a little hand-wavey. Any (non anecdotal) source/evidence for this?

I've seen one paper on this that, if I remember correctly, said there wasn't a measurable effect. I forget how good of a study it was or where I saw it -- should be easy to find.

That said, I do on occasion do this as well because it makes sense in my head and there's minimal risk to doing so. Have had good experiences doing so but it definitely feels a little voodoo-ish.

 

[deleted109597]

This seems a little hand-wavey. Any (non anecdotal) source/evidence for this?

What part? The dilt being more effective at an hour? Just from that terrible rag "Resuscitation"

Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia - PubMed

Slow infusion of calcium channel blockers is an alternative to adenosine in the emergency treatment of stable patients with SVT. Calcium channel blockers are safe and affordable for healthcare systems where the availability of adenosine is limited.

www.ncbi.nlm.nih.gov

The hypotension calcium thing?

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

www.aliem.com

Also, there's that whole "when they overdose on it this is one of the ways we treat it"

Cochrane also declares them equivalent (but also non-statistically significant different effectiveness of CCBs).

Adenosine versus intravenous calcium channel antagonists for tachycardia in adults

www.cochrane.org

Would you choose adenosine? - First10EM

Adenosine is many clincians' first line choice for SVT. I think it is a bad choice. These are the reasons why and the evidence.

first10em.com

https://www.nuemblog.com/blog/2018/5/25/psvt

 

[PTPoeny]

I wonder if there is some selection bias. In the PCICU we break SVT with vagal maneuvers all the time-usually pushing their legs up into their chest or ice to the face. I even work with a nurse who has SVT herself on a regular basis and goes and does a headstand and breaks it every time. Of course that means she doesn't end up in the ED.

(She told this to one patient who then wanted to try it for his SVT... But he was 5 and didn't have the arm strength so it resulted in several nurses going into his room each time he went into SVT and picking him up by his ankles. It worked every time, and he loved it! But it was a bit labor intensive...)

 

[Apollyon]

The pediatric physiology differences, I believe, don't extend into much overlap into the adult world.

 

[RustedFox]

I'm sorry, but just what is "PCICU"?

 

[Apollyon]

I'm sorry, but just what is "PCICU"?

Pediatric cardiac icu. Since we didn't even have one of those at Duke, I'm guessing it's ultra rare/ivory tower/not many of them.

 

[RustedFox]

Pediatric cardiac icu. Since we didn't even have one of those at Duke, I'm guessing it's ultra rare/ivory tower/not many of them.

Aye-aye.

MICU.
SICU.
PICU.
NICU.

These are pretty standard.

PCICU... nah.

 

[Apollyon]

TICU.
NSICU.

Trauma, Neurosurgical. The Neuro ICU kinda gets shoehorned out of it.

 

[MechEDoc]

DICU.

Urology ICU.

 

[deleted859535]

DICU.

Urology ICU.

One of the highlights of this thread.

 

[WildcatS11]

What part? The dilt being more effective at an hour? Just from that terrible rag "Resuscitation"

Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia - PubMed

Slow infusion of calcium channel blockers is an alternative to adenosine in the emergency treatment of stable patients with SVT. Calcium channel blockers are safe and affordable for healthcare systems where the availability of adenosine is limited.

www.ncbi.nlm.nih.gov

The hypotension calcium thing?

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

www.aliem.com

Also, there's that whole "when they overdose on it this is one of the ways we treat it"

Cochrane also declares them equivalent (but also non-statistically significant different effectiveness of CCBs).

Adenosine versus intravenous calcium channel antagonists for tachycardia in adults

www.cochrane.org

Would you choose adenosine? - First10EM

Adenosine is many clincians' first line choice for SVT. I think it is a bad choice. These are the reasons why and the evidence.

first10em.com

https://www.nuemblog.com/blog/2018/5/25/psvt

Thanks for the information.

I was only talking about the “calcium solving the hypotension” bit.

Based on that aliem review - there are actually no diltiazem trials which showed any statistical benefit in pretreating with calcium. Sure you can try to extrapolate with verapamil, if you want.

I’m not saying don’t do it. But it’s obviously not purely evidence based. Hence hand-wavey.

Also, if you are really treating CCB OD with Ca2+, then you’re not doing it well. Sure you have a goal to keep an adequate amount of calcium in the plasma, but let’s be real, that does not truly help overcome the OD. We have a handful of real treatments.