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. Quickly reposition patient's head of bed to flat and have the other assistant raise legs to 45° for another 15 seconds
  4. Return head of bed to 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
  • Perform with caution in elderly patients and those with a history of cardiovascular or neurologic events, though the complication rate is low[2]


  • Often successful with ice or ice-water application to face for at least 10 seconds (physiologically similar to mammalian diving reflex, and works best in infants up to 6 months of age)

See Also

External Links


  1. Appelboam, A, et al. Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study. BMJ, 2014; 4(3):e004525.
  2. Lacerda, GC, et al. Complications related to carotid sinus massage in 502 ambulatory patients. Arq Bras Cardiol, 2009; 92(2)