Vagal maneuvers

Modified positional valsalva

Modified positional valsalva


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  • 10ml syringe with plunger
  • Two assistants - one to adjust head of bed and another to raise/lower legs.


  1. Position patient with legs flat and head of bed to 45°
  2. Have patient attempt to blow out plunger of 10ml syringe (or Valsalva around 40mmHg) for 15 seconds.
  3. Then quickly reposition patients head of bed to flat and have the other assistant raise legs to 45° for another 15 seconds.
  4. Return patient to head of bed at 45° and continue to monitor for resolution for 1 minute.
  5. Repeat if needed.

Carotid sinus massage

  • Ideal duration of 15 seconds[1]
  • Auscultate to rule out bruits in carotid artery before performing
  • Perform ONE side at a time


  • Often successful with ice application to face

See Also


  1. Appelboam, A, et al. Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study. BMJ, 2014; 4(3):e004525.