When is Fast too FAST?

“Is the problem causing the rhythm or is the rhythm causing the problem?”

If the answer is the latter (and the patient has a pulse), you are probably dealing with a heart rate in excess of 150b/min in the adult patient.

So what does this have to do with REVERT?

If you consider vagal maneuvers for the conversion of a SUPRA-VENTRICULAR TACHYCARDIA, you should be thinking about using the modified valsalva maneuver to achieve conversion.

For the full algorithm referenced above refer to: http://www.resus.co.za/index.php/tachycardia-management

So what is the modified Valsalva?

First off: lets start with some of the basic maneuvers that are available for the conversion of an SVT (fast, narrow, regular rhythm with a pulse).

With slightly less intensity that displayed to the right… the valslava maneuver is described as “a forceful attempted exhalation against a closed glottis”.

The result of the valsalva maneuver is an eventual decrease in the heart rate through a system of complex physiological mechanisms. (for more information on the exact physiology follow the link: http://www.cvphysiology.com/Hemodynamics/H014)

There are a number of ways this maneuver can be performed

Now we modify it?

The patient performs the valsalva maneuver as normal in a 45 degree head up position. They attempt to maintain pressure for at least 15 seonds.

At the end of the attempt, the patient’s head is dropped to flat and the legs are raised to 45 degrees for 15 seconds.

The patient is then returned to seated comfortably, and monitored closely.

OK…but why?

Post written by @epicEMC

References:

Appelboam A, Reuben A, Mann C et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet. 2015;386(10005):1747-1753.

Bouthillet, T. 2016. SVT, Adenosine, and Postural Modification to the Valsalva Maneuver (REVERT Trial). available online:[https://www.ecgmedicaltraining.com/svt-adenosine-revert-trial/].

Rescuscitation Council of South Africa. 2016. Tachycardia Management Algorithm. available online: [http://www.resus.co.za/index.php/tachycardia-management].