[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical skills](https://durgical.com/en/clinical-skills/) › [Airway and cardiac procedures](https://durgical.com/en/clinical-skills/areas/airway-cardiac/) › Vagal manoeuvres and carotid sinus massage

# Vagal manoeuvres and carotid sinus massage

- Procedure

Simple actions such as straining or pressing gently on the neck slow the heart and can stop some fast heart rhythms.

Updated Nov 13, 2026

## Key points

- First step for a stable regular narrow-complex tachycardia; adenosine follows if they fail.
- Modified Valsalva: strain semi-recumbent, then lie flat with legs raised; converts more often than the standard method.
- Carotid sinus massage: auscultate for bruits first; one side at a time, briefly, with ECG monitoring.
- Unstable patient (shock, syncope, ischaemia, heart failure): synchronised cardioversion, not vagal manoeuvres.
- Flutter and atrial tachycardia rarely convert, but the slower rate reveals the atrial activity.

On this page

- The basics Key points
- What it is
- Indications
- Equipment
- Step by step (and why)
- Next step
- Elsewhere in DurgiPedia

- Clinical Complications

- Safety Contraindications and precautions

- Study Test yourself

- Connections Connections

## What it is

Vagal manoeuvres raise vagal (parasympathetic) tone to slow conduction through the atrioventricular (AV) node. In a re-entrant supraventricular tachycardia that uses the AV node as part of its circuit (AV nodal re-entry or AV re-entry through an accessory pathway), this transient block can break the circuit and restore sinus rhythm. In atrial flutter or atrial tachycardia they do not usually convert the rhythm, but the brief AV block slows the ventricular rate and unmasks flutter waves or P waves, which helps the diagnosis. They are the first step in a stable patient with a regular narrow-complex tachycardia, before adenosine. The Valsalva manoeuvre is forced expiration against a closed airway: the strain phase reduces venous return, and on release the rise in blood pressure triggers the baroreceptor reflex. The modified Valsalva manoeuvre adds a postural change: the patient strains semi-recumbent, then is laid flat with the legs raised as the strain ends; this increases the reflex and converts more often than the standard technique. Carotid sinus massage stimulates the baroreceptors at the carotid bifurcation directly, on one side only and with continuous ECG monitoring, after excluding carotid disease. In infants, cold applied to the face triggers the diving reflex. Pressure on the eyeballs is not used because it can injure the eye.

## Indications

- Haemodynamically stable regular narrow-complex tachycardia, presumed AV nodal or AV re-entry.
- Diagnosis of a regular tachycardia: slowing the ventricles may reveal flutter waves or ectopic P waves.
- Recurrent known supraventricular tachycardia: patients can be taught the manoeuvre to use at onset.
- Carotid sinus massage also helps to diagnose carotid sinus hypersensitivity in unexplained syncope, in a monitored setting.

## Contraindications and precautions

- Haemodynamic instability: go to synchronised cardioversion; do not delay.
- Carotid sinus massage: avoid with a carotid bruit, known carotid stenosis, recent stroke or TIA, or recent myocardial infarction.
- Valsalva: caution in recent myocardial infarction, aortic stenosis, glaucoma or retinopathy, and recent eye surgery.
- Modified Valsalva: the leg raise is unsuitable when the patient cannot lie flat or has the legs injured.
- Pre-excited atrial fibrillation (irregular, broad and varying): vagal manoeuvres and AV-nodal blockers are not used.
- Never apply pressure to the eyeballs, and never massage both carotids at once.

## Equipment

- Continuous ECG monitoring and a 12-lead ECG recorder to capture the rhythm before, during and after.
- Blood pressure monitoring and pulse oximetry.
- A syringe for the patient to blow into, or a manometer, to standardise the strain.
- A bed or trolley that tilts flat quickly, for the modified technique.
- Intravenous access, resuscitation equipment and a defibrillator nearby; adenosine available if vagal manoeuvres fail.

## Step by step (and why)

- Assess ABCDE and look for adverse features — an unstable patient needs a shock, not a manoeuvre.
- Record a 12-lead ECG and keep continuous monitoring — the rhythm at the moment of change is diagnostic.
- Explain the manoeuvre and practise the strain — a full, sustained strain is what triggers the reflex.
- Valsalva: seat the patient semi-recumbent and ask for a strain of about 15 seconds, blowing into a syringe — this lowers venous return.
- Modified: at the end of the strain, lay the patient flat and raise the legs for about 15 seconds — the rise in venous return boosts the reflex.
- Carotid massage: auscultate both carotids first; with the neck turned away, massage one side at the angle of the jaw briefly.
- Watch the monitor throughout and stop as soon as the rhythm changes — prolonged pauses or bradycardia can follow.
- Repeat the manoeuvre once if it fails, then move to adenosine — repeated failed attempts only delay treatment.
- Record a 12-lead ECG after conversion and document the manoeuvre and its effect — the sinus trace may show pre-excitation.

## Complications

- Sinus pauses, bradycardia or transient asystole after conversion, usually brief.
- Hypotension and lightheadedness, especially when sitting up or with carotid massage.
- Stroke or TIA from carotid massage, from dislodging plaque in a diseased artery.
- Ventricular arrhythmias, rarely, particularly with digoxin toxicity or ischaemia.
- Failure to convert, which is common and is a reason to move on, not to keep trying.

## Next step

- Converted: record a 12-lead ECG in sinus rhythm and look for pre-excitation (short PR, delta wave).
- Not converted and stable: adenosine with continuous ECG recording, as local protocol sets.
- Becomes unstable at any point: call a senior and prepare synchronised cardioversion.
- Irregular or broad-complex tachycardia: seek senior or cardiology advice before any AV-nodal blocker.
- Before discharge, teach the patient the modified Valsalva for future episodes and arrange follow-up for recurrent or pre-excited cases.

## Test yourself

Think of the answer, then tap the question to see it.

## How do vagal manoeuvres terminate an AV nodal re-entrant tachycardia?

They increase vagal tone, which slows conduction and lengthens refractoriness in the AV node; the re-entry circuit through the node is broken and sinus rhythm returns.

## What is the modified Valsalva manoeuvre?

A strain of about 15 seconds in the semi-recumbent position, followed at once by lying flat with the legs raised; it converts SVT more often than the standard Valsalva.

## What must be checked before carotid sinus massage?

Auscultation of both carotids for bruits and a history of stroke, TIA or recent myocardial infarction; massage only one side, briefly, with continuous ECG monitoring.

## Why might vagal manoeuvres help in atrial flutter even if they do not convert it?

The transient AV block slows the ventricular rate and reveals the flutter waves, confirming the diagnosis.

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## Elsewhere in DurgiPedia

- [The baroreceptor reflex](https://durgical.com/en/physiology/the-baroreceptor-reflex/)
- [How arrhythmias arise](https://durgical.com/en/physiology/how-arrhythmias-arise/)
- [The cardiac conduction system](https://durgical.com/en/physiology/the-cardiac-conduction-system/)

## Connections

## Related 5

- [Narrow-complex tachycardia (SVT)](https://durgical.com/en/clinical-skills/narrow-complex-tachycardia/)
- [Pre-excitation: Wolff–Parkinson–White](https://durgical.com/en/clinical-skills/pre-excitation-wolff-parkinson-white/)
- [Atrial fibrillation and atrial flutter](https://durgical.com/en/clinical-skills/atrial-fibrillation-and-atrial-flutter/)
- [Recording a 12-lead ECG](https://durgical.com/en/clinical-skills/recording-a-12-lead-ecg/)
- [Defibrillation and synchronised cardioversion](https://durgical.com/en/clinical-skills/defibrillation-and-synchronised-cardioversion/)

## Related conditions 5

- [Supraventricular tachycardia (AVNRT, AVRT)](https://durgical.com/en/conditions/supraventricular-tachycardia/)
- [Wolff-Parkinson-White syndrome](https://durgical.com/en/conditions/wolff-parkinson-white-syndrome/)
- [Atrial flutter](https://durgical.com/en/conditions/atrial-flutter/)
- [Syncope (vasovagal, orthostatic hypotension, cardiac)](https://durgical.com/en/conditions/syncope/)
- [Carotid artery stenosis](https://durgical.com/en/conditions/carotid-artery-stenosis/)

## In Pharmacology 1

- [Adenosine](https://durgical.com/en/pharmacology/adenosine/)

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Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: [Vagal Maneuver](https://www.ncbi.nlm.nih.gov/books/NBK551575/) (StatPearls (NCBI Bookshelf), 2023).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/clinical-skills/vagal-manoeuvres-and-carotid-sinus-massage/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-skills/vagal-manoeuvres-and-carotid-sinus-massage/