I never had great luck with vagal maneuvers. Â Admittedly when I was a new medic, I didnâ€™t particularly want them to work. Â I wanted to give Adenosine, and watch the strip suddenly go asystole and then some wild funky beats before correcting to a nice sinus tack in the 120â€™s, way better than the 200â€™s I encountered. Â Paramedic as savior! Â I remember once how upset I was when I encountered a man in an PSVT in a doctorâ€™s office. Â As I got out my IV kit, the doctor ordered me to just take the patient to the hospital so they could see the rhythm for themselves. Â Okay, I said, fully determined to work my magic in the ambulance. Â Unfortunately for me, carrying the man down the stairs, caused a brief jostle and wallah, he was out of the PSVT. Â Drat.
In time though I collected the experience of patientsâ€™ extreme uncomfortableness with Adenosine. Â Theyâ€™d clutch their chests in terror as their hearts stopped. Â Two actually told me they would rather be shocked than get that drug. Â Another pleaded with me not to give it to her, and even though she was in a clear PSVT, I went with Cardizem instead, and it worked, gradually slowing her rate from the 200s to the 90s. Â She was very thankful.Â
So eventually I began always attempting the vagal maneuvers. Â Hold your breath and bear down, cough, blow through a straw, carotid massage, face in ice for the younger patients. Â But the vagal maneuvers never worked for more than a moment and the patients often looked at me like I had two heads.
Then I read about a new vagal maneuver in the American Journal of Emergency Medicine.
Novel vagal maneuver technique for termination of supraventricular tachycardias
Â Pretty simple. Â You sit the person up, and then have them lay backwards. Â How hard is that?
We get called to a school. Â 16 year old cranking at 250. Â Diaphoretic, chest pain. Â Never happened before. Â Nurse tells me, she has tried vagal maneuvers with no results. Â Letâ€™s try this new one, I say. Â And so we do it. Â (Except I get it confused with another one, and in addition to having her lay back, we also lift her legs up.) Â We do this in front of an audience of maybe twenty people, teachers, nursing staff, firefighters.
Hereâ€™s how it went:
Awesome. Â Thank you very much. Â Drop the mic.
Patient instantly feels better, and has no recurrence. Â I tell everyone about it.
Couple weeks later. Â We have a 350 pound man heart going at 180 with a regular narrow complex. Â Vagal maneuvers have not worked from the first responding medic. Â Patient has a history of rapid heart rate, sometimes relieved by meds, others by electricity.
The other medic says, â€œYou want to try the new vagal maneuver you told me about?â€
â€œLet us do so,â€ I say.
We explain what we are going to do. Â Since he is lying sprawled across the bed and he is very big, we have a hard time sitting him up. Â He moans and groans and flops. Â We finally have him semi-sitting up. Â We lay him back down and lift his legs up (there we go again with the lifted legs). Â His heart keeps going at 180. Â He yells at us to get him to the hospital. Â The manâ€™s family and the fire department look at us like we each have three heads.
We earn back a little bit of trust when 25 and 25 of Cardizem works after a failed 6 and 12 of Adenosine (the Adenosine replete with the clutching the chest Iâ€™m dying drama so pronounced that we can’t get a look at the underlying rhythmÂ due to all the artifact).