Date Published

September 29, 2016

Updated For

ALS PCS Version ALS PCS Version 5.2


Question: A recent study, published in the Lancet showed an alternative way of performing a Valsalva maneuver, that is much more effective.

It is described and shown in a video here:

Is it acceptable for us to perform this when a Valsalva is called for in our directives?


 We absolutely love seeing great evidence-based questions pop up on Ask MAC!

The short answer to your question is: yes, as an ACP you can use this modified Valsalva technique for those patients that meet criteria for Valsalva attempt (narrow complex regular rhythm, normotensive, unaltered LOC; that are not in sinus tachycardia nor atrial fibrillation or atrial flutter).

The best summary of the role of vagal maneuvers for SVT was written by Dr Bradford in the January 2011 newsletter on page 7.  It is a great read and the link is here:

For those that have not heard of, or read the REVERT trial: It was a RCT performed in Britain comparing 1:1 regular Valsalva vs Modified Valsalva.  The modified Valsalva technique is performed by having the patient in semi-recumbent position, blowing into a 10cc syringe for 15seconds (the Valsalva portion) they then are positioned supine, with passive leg raise.  They found greater success with the modified technique being that 43% vs 17% of their patients were in NSR after 1min following the procedures.  TLOhe downside to this technique is that it takes more patient movement than the original Valsalva.

A video of this technique, from the authors; can be found here:



Advanced Care Paramedic (ACP)

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