Super Ventricular Tachycardia (SVT)

[vcfd35s]

I was watching Grey's Anatomy this evening and one of the doctors did something that I have never seen before and I wanted to see if it was actually done in the field. A patient was in SVT and the doctor came in and did a "carotid massage". She rubbed the carotid artery until the heart rate slowed to a normal rate. Is this something that medics do, or was this some more of hollywood's wonders? If it is something that we really do, what is the point of the massage; what is the purpose? I am only an EMT, so any knowledge would be much appreciated. Thanks guys!!

[scratrat]

First, it's called SUPRA not super.

And carotid massage is a vagal manuvuer kind of. Same thing as telling them to 'bear down' like they are to deficate, which is a Valsalva Maneuver.These maneuvers stimulate the vagus nerve, which can slow conduction of electrical impulses that control your heart rate. Some systems allow for the bearing down but not carotid massage. It's different everywhere you go though. Carotid sinus massage has a lot of contraindications and some badddd juju associated with it.

[Lithium]

Yes, carotid sinus massage (CSM) is one of the methods that can be used to attempt to resolve (P)SVT.

Essentially, by applying pressure to the carotid artery, the baroreceptors pick up an increase in blood pressure, and this will lead to a stimulation of the vagus nerve to slow down the heart rate in order to decrease the BP. Another method similar to this is to ask the patient to take a deep breath in, hold it and bear down as if they are trying to move their bowels.

There are some risks, and one of the assessments to be performed prior is the assessment of carotid bruits. If bruits are present, consider one of the other methods of cardioversion (either pharmacological or electrical).

Jacob

[crazycanuck]

As you know, there are several different types of SVT within the umbrella of atrial, or supraventricular tachycardias. There are atrial ectopic tachycardias, which originate from one or more irritable focus/foci in the atria. There are also AV re-entry tachycardias (AVRT) and AV-nodal re-entry tachycardias (AVNRT) and these can all be classified from specific EKG classification of intervals and origin of p-waves, etc. which is well above my capability in this discussion.

The reason I bring this up, is that the type/origin, and rate of the SVT may dictate whether or not you will have success with Vagal maneuvers such as Valsalva or carotid sinus massage. Also as previously mentioned, CSM is contraindicated in the presence of carotid bruits, as well as in individuals with carotid-sinus hypersensitivity w/o a pacer implanted, and in persons with hx of atherosclerotic disease.

The success for vagal maneuvers may also have to due with the individual sensitivity to the carotid sinus reflex, and the presenting rate of the rhythm.

As for whether or not this is indicated in your protocols, I suspect it is possible in some areas and not in many others.

____

CC

And for reference just in case you're interested:

eurheartj.oxfordjournals.org/cgi/reprint/25/15/1310.pdf (pdf is available in entirety online, worth a look)

These others you may be able to get abstract, but I think you need fulltext access:

Lim SH, Anantharaman V, Teo WS, Goh PP, Tan AT. Comparison of treatment of supraventricular tachycardia by Valsalva maneuver and carotid sinus massage. Ann Emerg Med. 1998 Jan;31(1):30-5.

Journal Watch Emergency Medicine, Vagal maneuvers for SVT:Should we bother? Vol. 1998, Issue 301, 10 March 1, 1998

[Code 8 Paramedic]

very good replies everyone... just to add my two cents... I typically don't do it... i stick with the bear down method of vagal maneuvers. and just as a piece of trivia... heart transplant patients don't respond to vagal maneuvers, as the vagus nerve doesn't innervate the heart

[medic001918]

We typically don't do carotid sinus massage in the field due to the possibility of releasing a carotid bruit and having an embolism floating around. If you are going to do CSM, you are supposed to listen with your stethoscope prior to the procedure to see if you can hear a bruit. The traditional method in the field is trying to have the patient vagal themselves down prior to using drug therapy.

Shane

NREMT-P

[chbare]

Off topic; however, a little pearl related to the discussion. Heart transplant patients will not have a response to atropine as well. This too is related to the separation of the heart from the nervous system. In addition, heart transplant patients will not experience typical symptoms of AMI. Often, a chief complaint of dyspnea or CHF like S/S are seen in the heart transplant patient experiencing acute cardiac problems.

Take care,

chbare.

[Ridryder 911]

I have found CSM more effective than valsalvas. I do listen to bruits as well, and do not perform it on those >65. I have had great success with the procedure, in lieu of giving of Adenocard. One of the cardiologist I witnessed used it routinely for most tachyrhythmias. Very few times I witnessed medication for reduction of rate.. interesting modality.

R/r 911

[AZCEP]

That's because you are the embodiment of "old school" Rid.

CSM is very effective when done appropriately. Unfortunately, there has been an entire generation of providers that have not been taught how to do it right. Don't think that by watching a medical drama, you will have enough knowledge to perform it correctly. It is a bit risky in educated hands, more so in under-educated ones.

[brock8024]

In my PC III class we was taught to do this only if the patient was 50 and we felt and listened to the carotids. We was also not allowed to use SVT we had to tell the difference between atrial tachycardia and junctional tachycardia.