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Upside-down position for SVT in children
Background: Supraventricular tachycardia (SVT) is the commonest arrhythmia in children, having two peaks – one in the first year of life and another around age 6. We generally attempt vagal manoeuvres before medication or electricity to restore sinus rhythm. The commonest techniques are the ‘mammalian dive reflex’ (submerge the face of an infant in freezing water) and the Valsalva method (forced expiration against a closed glottis). There is, however, a new kid on the block – the imaginatively-named upside-down position. This is the first pilot study of this technique. The authors are currently conducting a larger RCT.
Bronzetti G, Brighenti M, Mariucci E, et al. Upside-down position for the out of hospital management of children with supraventricular tachycardia. Int J Cardiol 2018;252:106-109
The paper: A single-centre study of 24 children with known paroxysmal SVT. The parents were taught to identify SVT using palpation of the brachial or carotid pulse and with a stethoscope. Each family was randomly assigned to standard vagal manoeuvre (VM – blowing into a 10ml syringe for 15 seconds) or upside-down manoeuvre (UD – manually flipping children weighing less than 30kg or helping heavier children to do a handstand for 30 seconds). If this was unsuccessful, the other manoeuvre was attempted. The rate of cardioversion at the first attempt was 33% (VM), compared to 67% (UD). Of those in whom the attempted manoeuvre was unsuccessful, 50% subsequently cardioverted with UD, whereas none cardioverted with VM. In addition to these results, parents reported that their children enjoyed the upside-down position more than syringe-blowing.
The bottom line: This is a tiny pilot study, but the results are very much in favour of the upside-down position for the treatment of SVT in children.
Note: It is well-known that vagal manoeuvres work better if they are carried out before adrenergic tone rises, which is why they work better when performed soon after the onset of SVT, and at home rather than in the ED
Expert commentary:“Interesting… to be honest I have never tried this technique. However, it seems very promising and I’m glad that further research is happening. The British Heart Foundation leaflet for parents on SVT actually recommends the upside-down method so it’s certainly becoming well-established.”(Mohsin Jafri, Paediatric Consultant)
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By Barrie StevensonBackground: Supraventricular tachycardia (SVT) is the commonest arrhythmia in children, having two peaks – one in the first year of life and another around age 6. We generally attempt vagal manoeuvres before medication or electricity to restore sinus rhythm. The commonest techniques are the ‘mammalian dive reflex’ (submerge the face of an infant in freezing water) and the Valsalva method (forced expiration against a closed glottis). There is, however, a new kid on the block – the imaginatively-named upside-down position. This is the first pilot study of this technique. The authors are currently conducting a larger RCT.
Bronzetti G, Brighenti M, Mariucci E, et al. Upside-down position for the out of hospital management of children with supraventricular tachycardia. Int J Cardiol 2018;252:106-109
The paper: A single-centre study of 24 children with known paroxysmal SVT. The parents were taught to identify SVT using palpation of the brachial or carotid pulse and with a stethoscope. Each family was randomly assigned to standard vagal manoeuvre (VM – blowing into a 10ml syringe for 15 seconds) or upside-down manoeuvre (UD – manually flipping children weighing less than 30kg or helping heavier children to do a handstand for 30 seconds). If this was unsuccessful, the other manoeuvre was attempted. The rate of cardioversion at the first attempt was 33% (VM), compared to 67% (UD). Of those in whom the attempted manoeuvre was unsuccessful, 50% subsequently cardioverted with UD, whereas none cardioverted with VM. In addition to these results, parents reported that their children enjoyed the upside-down position more than syringe-blowing.
The bottom line: This is a tiny pilot study, but the results are very much in favour of the upside-down position for the treatment of SVT in children.
Note: It is well-known that vagal manoeuvres work better if they are carried out before adrenergic tone rises, which is why they work better when performed soon after the onset of SVT, and at home rather than in the ED
Expert commentary:“Interesting… to be honest I have never tried this technique. However, it seems very promising and I’m glad that further research is happening. The British Heart Foundation leaflet for parents on SVT actually recommends the upside-down method so it’s certainly becoming well-established.”(Mohsin Jafri, Paediatric Consultant)