Trick of the Trade: Valsalva maneuver by pressing on the abdomen

A patient presents to triage in rapid SVT rhythm. While you are trying to get an IV in the patient and drawing up adenosine, you have the patient perform a Valsalva maneuver to see if increased vagal tone itself will break the arrhythmia. Unfortunately, she is unable to understand your instructions.

Trick of the Trade

Apply firm pressure to the abdomen and have the patient push you away

Thanks to Dr. David Johnson (Stanford-Kaiser EM resident) for sharing this tip, which broke a patient with pre-excitation syndrome with a narrow complex heart rate of about 200 bpm. Here’s his explanation:

I feel that this is an easy, coachable way for a patient to vagal themselves.

Lay a patient supine and have them relax their abdomen.
Place your hands near the umbilicus and apply firm pressure.
Place your hands and take a stance similar to performing chest compressions.
Warn the patient that you will place a lot of pressure as you slowly press into the abdomen.
When you have a moderate degree of pressure, then ask the patient to lift you up or push you away with their stomach.
They will tense their abdominal muscles and bear down as you are pushed away.
Be prepared cause most are quite strong and you will actually want to put a lot of your weight on your hands as you encourage the patient to continue to push you up with their abdominal muscles.