Vagal maneuvers

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]

Reverse valsalva

  • First described in a 2020 case series from France by Gaudart, et al.[3]
  • Initial data scant but promising with 10/11 cardioverting to normal sinus rhythm, including 4 who had failed the modified Valsalva maneuver


  • No assistant or items necessary


  1. Have the patient exhale completely in a sitting position
  2. Pinch nose and close mouth tightly
  3. Attempt to inhale against resistance for 10 seconds


  • 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)
  3. Gaudart P, Cazes N, Simon K, Larger D, Deharo JC. The reverse vagal manoeuvre: A new tool for treatment of supraventricular tachycardia? Am J Emerg Med. 2021 Mar;41:66-69. doi: 10.1016/j.ajem.2020.12.061. Epub 2020 Dec 26. PMID: 33387931.