Andrew Appelboam

Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial

BACKGROUND The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5-20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness. METHODS We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation. This study is registered with Current Controlled Trials (ISRCTN67937027). FINDINGS We enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3-5·8; p<0·0001). We recorded no serious adverse events. INTERPRETATION In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients. FUNDING National Institute for Health Research.

Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study

Introduction The Valsalva manoeuvre (VM) is a recommended first-line physical treatment for patients with re-entrant supraventricular tachycardia (SVT), but is often ineffective in standard practice. A failed VM is typically followed by treatment with intravenous adenosine, which patients often find unpleasant. VM effectiveness might be improved by a modification to posture which exaggerates the manoeuvres vagal response and reduces the need for further emergency treatment. Methods and analysis This is a multicentre randomised controlled clinical trial in 10 UK emergency departments (EDs). It compares a standard VM with a modified VM incorporating leg elevation and a supine posture after a standardised strain in stable adult patients presenting to the ED with SVT. The primary outcome measure is return to sinus rhythm on a 12-lead ECG. Secondary outcome measures include the need for treatment with adenosine or other antiarrhythmic treatments and the time patients spend in the ED. We plan to recruit approximately 372 patients, with 80% power to demonstrate an absolute improvement in cardioversion rate of 12%. An improvement of this magnitude through the use of a modified VM would be of significant benefit to patients and healthcare providers, and justify a change to standard practice. Ethics and dissemination The study has been approved by the South West—Exeter Research Ethics Committee (REC reference 12/SW/0281). The trial will be published in an international peer reviewed journal. Study findings will be sent to the European and International resuscitation councils to inform future revisions of arrhythmia management guidelines. Results The trial will also be disseminated at international conferences and to patients through the Arrhythmia Alliance, a patient support charity. Registration The study is registered with Current Controlled Trials (ISRCTN67937027) and has been adopted by the National Institute for Health Research (NIHR) Clinical Research Network.

Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique.

Sternal fractures cause considerable pain, and a proportion of patients require admission for analgesia. Local anaesthetic techniques have been used to reduce the pain from chest wall injuries and may reduce complications from these injuries. The use of a local anaesthetic delivered via a sternal catheter over a fractured sternum has been described in a patient whose pain was inadequately controlled with opiates. This technique was recently offered to patients in the emergency department at the Royal Devon and Exeter Hospital, Exeter, UK, and the experiences of patients and doctors are reported. Findings from this first case series suggest that the technique seems to be effective, well tolerated and acceptable to patients.

Modified Valsalva manoeuvre to treat recurrent supraventricular tachycardia: description of the technique and its successful use in a patient with a previous near fatal complication of DC cardioversion

Patients with attacks of re-entrant supraventricular tachycardia (SVT) frequently present to the emergency department (ED). The Valsalva manoeuvre (VM) is the most effective and safe vagal manoeuvre and advocated as the first-line treatment in stable patients but has a relatively low cardioversion success rate. Improving its efficacy would reduce patients’ exposure to the side effects and complications of second-line treatments and has other potential benefits. We describe a modification to the VM, which is currently being studied, and present the case of a 23-year-old patient who was successfully treated with this modified VM after a previous near-fatal complication of direct current (DC) cardioversion.

Improving paediatric pain management: introducing the ‘Pain Passport’

The ‘Pain Passport’ is a novel method of improving the management of pain in children. It consists of a leaflet carried by the patient which records serial pain scores. It attempts to empower patients and prompt medical and nursing staff to evaluate the childs pain. Preliminary audit data in support of this concept are encouraging.

Cardioversion of a supraventricular tachycardia (SVT) in a 7-year-old using a postural modification of the Valsalva manoeuvre

A boy aged 7 years presented with his parents to the emergency department (ED). He had a known diagnosis of paroxysmal supraventricular tachycardia (SVT) and was under the care of paediatricians. He had been suffering episodes of palpitations and chest pain for over a year and had been prescribed atenolol 25 mg ON, though the side effects meant he had not taken it for a month prior to presentation. He had 2 previous confirmed episodes of SVT, one that reverted with Valsalva manoeuvres, and the other with intravenous adenosine. In the ED, an ECG was recorded showing SVT at 180 bpm. Aside from his tachycardia, he was haemodynamically stable. The postural modification of the Valsalva technique was performed within 5 min of arrival, with reversion to sinus rhythm occurring during the leg-lift phase on the first attempt. After 30 min of observation, the child remained stable and was discharged home.