Novel Vagal Maneuver

I never had great luck with vagal maneuvers.  Admittedly when I was a new medic, I didn’t particularly want them to work.  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 120’s, way better than the 200’s I encountered.  Paramedic as savior!  I remember once how upset I was when I encountered a man in an PSVT in a doctor’s office.  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.  Okay, I said, fully determined to work my magic in the ambulance.  Unfortunately for me, carrying the man down the stairs, caused a brief jostle and wallah, he was out of the PSVT.  Drat.

In time though I collected the experience of patients’ extreme uncomfortableness with Adenosine.  They’d clutch their chests in terror as their hearts stopped.  Two actually told me they would rather be shocked than get that drug.  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.  She was very thankful. 

So eventually I began always attempting the vagal maneuvers.  Hold your breath and bear down, cough, blow through a straw, carotid massage, face in ice for the younger patients.  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

 Pretty simple.  You sit the person up, and then have them lay backwards.  How hard is that?

We get called to a school.  16 year old cranking at 250.  Diaphoretic, chest pain.  Never happened before.  Nurse tells me, she has tried vagal maneuvers with no results.  Let’s try this new one, I say.  And so we do it.  (Except I get it confused with another one, and in addition to having her lay back, we also lift her legs up.)  We do this in front of an audience of maybe twenty people, teachers, nursing staff, firefighters.

Here’s how it went:

Awesome.  Thank you very much.  Drop the mic.

Patient instantly feels better, and has no recurrence.  I tell everyone about it.

Couple weeks later.  We have a 350 pound man heart going at 180 with a regular narrow complex.  Vagal maneuvers have not worked from the first responding medic.  Patient has a history of rapid heart rate, sometimes relieved by meds, others by electricity.

The other medic says, “You want to try the new vagal maneuver you told me about?”

“Let us do so,” I say.

We explain what we are going to do.  Since he is lying sprawled across the bed and he is very big, we have a hard time sitting him up.  He moans and groans and flops.  We finally have him semi-sitting up.  We lay him back down and lift his legs up (there we go again with the lifted legs).  His heart keeps going at 180.  He yells at us to get him to the hospital.  The man’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 I’m dying drama so pronounced that we can’t get a look at the underlying rhythm due to all the artifact).

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