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Vagal Maneuvers – Indications And Possible Complications

1. Tachycardia with narrowed QRS complex


–        In order to decrease conduction velocity and to increase the refractory period at the atrioventricular node level;

–        Decreased atrial refractory period;

–        Decrease in frequency electrical impulse formation in the sino-atrial node.

2. Exposure of the block location in case of atrioventricular block 2: 1


–        Increasing the block shows a suprahisian location;

–        Improving the atrio-ventricular conduction shows an infrahisian location.

3. Diagnosis of hypersensitivity of the carotid sinus


–        In case of syncope.

4. Supraventricular tachyarrhythmias

–        Increasing the block at the atrioventricular node level and highlighting atrial activity (P wave of atrial tachycardia or F waves of atrial flutter);

–        It can convert certain supraventricular tachycardias: intra-nodal reentrant tachycardia, rarely accessible and extremely rare that the beam can slow down or even convert atrial tachycardia.

Contraindications of vagal maneuvers


–        Carotid sinus massage is contraindicated in patients with murmurs or stenosis of the carotid arteries or transient ischemic attack (within the past 3 months).


–        Recent myocardial infarction, history of ventricular arrhythmias, immobilizer, blindness or cognitive impairment.

Complications of vagal maneuvers

–        Sinus pauses;

–        Atrioventricular block;

–        Rarely, tachyarrhythmias;

–        Neurological complications;Vagal3

–        Retinal detachment (in case of oculo-cardiac reflex);

–        Water intake, anxiety (if immersion reflex).

Vagal maneuvers as a diagnostic modality in tachyarrhythmias

1. Carotid sinus massage

Mode of action: glossopharyngeal nerve;

Method of making: patient in supine with head hyperextension can feel the carotid sinus (inferior on the mandible angle at the intersection with thyroid cartilage). It is applied pressure for 5-10 seconds with continuous ECG monitoring and TA;

Possible complications: dizziness, hypotension, syncope, ventricular tachycardia, ventricular fibrillation, asystole, neurological complications.

2. Valsalva maneuver

Mode of action: vagus nerve;Vagal1

Method of making: patient in supine, after a normal inspiration he is asked to expire forced with the glottis closed for 10 seconds. Signs of proper maneuver- distenisa of the jugular vein, facial congestion and abdominal muscle hyper-tonicity;

Possible complications: eardrum rupture, ventricular arrhythmias, systolic breaks

3. Diving reflex (immersion)

Mode of action facial nerve and vagus


Method of making: Patient in front of a pot of water with temperature of 10-20 degrees Celsius, large and deep enough for the patient to not touch the vessel with face or neck. After a regular inspiration, the patient is sinking with his face in the water; the more immersed surface is, the effect is more pronounced. The expected effect – bradycardia mediated by parasympathetic and vasoconstriction sympathetic mediated;

Possible complications: Anxiety, premature ventricular, aspiration, drowning.

4. Oculocardiac reflex (by pressing the eyeballs)

Mode of action: oculo-motor nerve;

Method of making: it is applied pressure on the eyeballs, the orbit or extra-ocular muscles;

Possible complications: Retinal detachment, ocular trauma, malignant ventricular arrhythmias.

Other maneuvers that may lead to the activation of the parasympathetic system: apnea, digital rectal examination, coughing, deep breathing, reflex-induced vomiting, intra-cardiac catheter placement, installation of a nasogastric tube, sitting on veins, Trendelenburg position.

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