A patient presents to triage in rapid SVT rhythm. While you are trying to get an IV in the patient and drawing up adenosine, you have the patient perform a Valsalva maneuver to see if increased vagal tone itself will break the arrhythmia. Unfortunately, she is unable to understand your instructions.
Trick of the Trade:
Apply firm pressure to the abdomen and have the patient push you away
Thanks to Dr. David Johnson (Stanford-Kaiser EM resident) for sharing this tip, which broke a patient with pre-excitation syndrome with a narrow complex heart rate of about 200 bpm. Here's his explanation:
I feel that this is an easy, coachable way for a patient to vagal themselves.
- Lay a patient supine and have them relax their abdomen.
- Place your hands near the umbilicus and apply firm pressure.
- Place your hands and take a stance similar to performing chest compressions.
- Warn the patient that you will place a lot of pressure as you slowly press into the abdomen.
- When you have a moderate degree of pressure, then ask the patient to lift you up or push you away with their stomach.
- They will tense their abdominal muscles and bear down as you are pushed away.
- Be prepared cause most are quite strong and you will actually want to put a lot of your weight on your hands as you encourage the patient to continue to push you up with their abdominal muscles.