#SimBlog: Modified Valsalva Manoeuvre (SVT)
““35-year-old female. Self-presented to the ED with h/o palpitations for last 2 hours (no chest pain or SOB).””
Observations
A – Patent
B – RR 21, Sats 98%
C – HR 175, BP 125/67
D – Alert
E – Pyrexial
Clinical Findings
Narrow complex tachycardia on ECG: "SVT"
No adverse signs
Why We Simulated?
Many of you will have come across the REVERT Trial published in the Lancet last year, and I suspect many of you will have also adapted your practice because of it.
For those of you who haven't read the paper it was an RCT carried out in several EDs in England to compare a standard valsalva against a modified valsalva manoeuvre for cardioverting patients presenting with SVT. (The SGEM summarises the paper here.)
The modified manoeuvre is as follows:
"The patient performs the standardised strain in a semi-recumbent position but immediately at the end of the strain they are laid flat and their legs raised by a member of staff to 45° for 15 s. Patients are then returned to the semi-recumbent position for a further 45 s before re-assessment of cardiac rhythm, initially by 3-lead ECG."
Why is it an interesting paper? Put simply it recommends an effective modification to current practice that doesn't cost anything extra and doesn't carry any real extra risks to the patient. It also potentially reduces the need to give adenosine (which some patients find quite an unpleasant experience).
In essence it fulfils the definition of quality care by being STEEEP:
Safe: do no harm; avoiding injuries from care aimed at helping patients.
Timely: without undue delay both for those who receive and those who give care.
Effective: produces desired results; services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit; disease prevention and early detection.
Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy; resourced appropriately and done competently.
Equitable: providing care that does not vary because of gender, ethnicity, disabilities etc. in the patient; or at population level because of geographic location, and socio-economic state.
Patient-centred: providing care that is respectful of and responsive to individual patient preferences, needs, and values; seamless; provided with respect and compassion.
The results of the paper itself show the modified valsalva returned 40% of patient to sinus rhythm compared to the standard valsalva working in 17% of patient. The number needed to be treated was only 4! So if you haven't put it into your practice it is really worth thinking about next time you see a patient with an SVT.
Further Reading:
- The Lancet: REVERT Trial
- SGEM: This is a SVT and I’m gonna REVERT it
- STEEEP Global Institute: Definitions
Learning Outcomes
If you attach the defibrillator during a chemical cardioversion consider also switching it on.
Adenosine should be given with a big flush, through a big line.
Positive Feedback
Good use of summaries to communicate with the team.
The were aware of and used the modified valsalva.
Team leader accepted their limitations and was willing to utilise the skills of others.
