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Pilot Study for a Novel Delta Carotid Sinus Massage in Increasing 대한응급의학회지 제 30 권 제 2 호 � 원저� Volume 30, Number 2, April, 2019 Procedure Pilot study for a novel delta carotid sinus massage in increasing parasympathetic tone: a randomized, prospective, cross-over, comparative study with conventional method Dong Ik Lee1, Tae Yong Shin2, Hong Chuen Toh3, Min Jung Lee1, Jung Hwan Ahn1 1Department of Emergency Medicine, Ajou University School of Medicine, Suwon, 2Department of Emergency Medicine, Bundang Jesaeng General Hospital, Seongnam, Korea, 3Acute and Emergency Care Centre, Khoo Teck Puat Hospital, Singapore Objective: This study examined the efficacy of new delta carotid sinus massage (CSM) versus conventional CSM (CM). Methods: This prospective, cross-over study was conducted on 26 healthy volunteers with a normal sinus rhythm. CM and delta CSM (DM) were performed in all participants. In both cases, the CSM was performed, where the maximal carotid pulse was palpated. DM differed from CM in that the physician moves the palpating finger in the opposite direction of the carotid pulse at least twice. The mean and longest R-R intervals and mean and lowest heart rates (HRs) at the baseline and during the procedure for each technique were compared. The mean differences between the baseline and procedure R-R intervals and the HRs for each technique were also evaluated. Results: The baseline mean and longest R-R intervals and baseline mean and lowest HRs were similar both groups (P>0.05). The procedure DM mean and longest R-R intervals (22.7±3.1, 26.4±4.9) were significantly greater than the CM corresponding values (22.0±3.1, 24.6±3.5; P<0.001, P=0.003). Procedure DM mean and lowest HRs (67.3±9.7, 58.6±10.7) were significantly lower than the CM corresponding values (69.4±10.0, 61.8±8.9; P=0.001, P=0.003). The differences in the R-R interval and HR between the procedure and baseline were significant (mean and longest R-R inter- vals with CM [1.3±1.5 and 2.1±1.9] vs. DM [2.0±1.4 and 3.8±3.1], P<0.001, P=0.004; mean and lowest HRs with CM [4.2±4.3 and 5.8±4.6] vs. DM [6.3±4.6 and 9.1±6.5], P<0.001, P=0.005). Conclusion: DM is more effective in generating a more potent vagal tone than CM. Keywords: Carotid sinus; Massage; Electrocardiography; Heart rate cessful conversion of supraventricular tachycardia (SVT) INTRODUCTION with CSM is generally low and very variable, from 11.8% to 48.5%, often necessitating subsueqent pharma- Pressure over carotid sinuses elicits a reflex parasym- cological intervensions such as intravenous adenosine.2,4,5 pathetic response, and can cause bradycardia due to neg- This variability could arise from factors related to the ative dromotropic and chronotropic effects on atrioven- location of the carotid sinus and adequacy and direction tricular nodes and sinus.1-3 Carotid sinus massage (CSM) of force applied.2,6 as a bedside diagnostic test and therapeutic intervention The vagal stimulating effect of CSM results from has been described two centuries ago, with Hering’s stretching or deformation of the wall of the carotid sinus, observation that the carotid sinus was stimulated by pres- in which the nerve endings are embedded.2 The stretching sure on the carotid artery, resulting in the termination of of the sinus could be initiated by a rise in static pressure paroxysmal tachycardia.2,4 Nevertheless, the rate of suc- or increased pulsatile flow, with the latter being more 책임저자: 안 정 환 경기도 수원시 영통구 월드컵로 164 아주대학교 의과대학 응급의학교실 Tel: 031-219-7750, Fax: 031-219-7760, E-mail: [email protected] 접수일: 2018년 8월 17일, 1차 교정일: 2018년 10월 2일, 게재승인일: 2018년 10월 3일 176 Delta carotid sinus massage / 177 September 2016. It was approved by the institutional Capsule Summary review board (IRB) at our hospital and it conformed to the principles outlined in the Declaration of Helsinki What is already known in the previous study (IRB No. XXIRB-MED-MDB-16-277). The written Carotid sinus massage (CSM) has been used as a bedside informed consent was obtained from the enrolled partici- diagnostic test and therapeutic intervention for more pants. The trial was registered in the Clinical Trial than two centuries. On the other hand, the conversion Registry of Korea with an assigned number of KCT rate of supraventricular tachycardia with conventional 0002139. CSM ranges from 11.8% to 48.5%. This variation in con- version rate could be related to the variability in the loca- 2. Participants tion of the carotid sinus, adequacy of force, and correct direction of the application of force. All participants enrolled in this study were volunteers recruited via posters placed in our hospital. Informed What is new in the current study written consent was obtained after explaining the aim This study showed that the new CSM technique could and design of this study. Inclusion criteria were self- elicit a greater vagal stimulation than the conventional reported general good health, age 18 to 60 years, sinus CSM performed with a static pressure. In the new tech- rhythm on initial electrocardiography (ECG), and nique, the physician moves the palpating finger over the absence of bruit over the carotid artery on direct auscul- carotid sinus in the opposite direction to the carotid tation. Exclusion criteria include being on any regular pulse at least twice, generating increased pulsatility of medication (other than oral contraceptives), a history of blood flow to the carotid sinus. This maneuver is called cardiorespiratory disease, syncope, orthostatic hypoten- “delta CSM.” sion, cerebrovascular accident, or transient ischaemic attack. Participants were informed not to smoke or con- sume alcohol or caffeine 6 hours before the procedure. effective than sustained pressure at stimulating the carotid Their demographic data were obtained upon recruitment. sinus.2,7 Applying Bernoulli’s principle, the speed of blood flow through a section of the blood vessel is 3. Randomization expected to increase as the size of the lumen decreases and vice versa. By pressing down on the carotid artery All participants were subjected to both CM and DM, but during the systole, hence decreasing its lumen, and in the order as determined by their allocation. Using the releasing this pressure in diastole, the normal pulsatility randomization sequence generated by a dedicated software of the arterial blood flow is augmented. When applied to (http://www.graphpad.com/quickcalcs), participants are CSM, this manoeuvre could potentially result in a greater randomized to one of the two groups: (1) right DM was vagal stimulation compared to sustained pressure. We performed first, followed by right CM; and (2) right CM call this new technique ‘delta CSM’ (DM), which is per- was performed first, and then right DM. Before and after formed with palpating finger essentially moving in the performing each test, there was a rest time of 3 minutes to opposite direction of the carotid pulse. The aim of this ensure that the participants have made full recovery to study is to investigate the efficacy of DM at raising vagal baseline, as the sinoatrial rate often return to baseline with- tone compared to conventional CSM (CM). in 10-15 seconds of completing the vagal manoeuvre.2,8 4. Intervention and measurements METHODS Fig. 1 outlines the study design. The procedure was 1. Study design and setting performed with the participant lying supine and only on the right carotid bulb, as the cardio-inhibitory effect has The study design was a prospective, randomized been reported to be greater on this side.4 The two CSM crossover trial, conducted between 11 August and 12 techniques were performed at the same location indicat- 178 / Dong Ik Lee et al. Fig. 1. Study flow. ed with a marker, with the participant’s head tilted back- Cardiac activity was recorded on continuous ECG strip ward and turned slightly to the left. The physicians who (lead II) running at 25 mm/sec (Heartstart XL, Philips, performed the CSM were board-certified emergency Andover, MA, USA). The linear R-R interval, which physicians and not members of the research team. CM was known as an indirect indicator of the level of vagal was performed by applying direct firm pressure for 10 tone, was calculated directly from ECG tracing using the seconds in a posteromedial direction where the carotid electronic ruler (Digital Vernier Caliper, Lenaenergy, pulse was the most strongly palpated, usually immediate- Daegu, Korea) and converted to time intervals.6,8 R-R ly above the level of the thyroid cartilage and anterior to interval was expressed in seconds. Marks indicating the the sternocleidomastoid muscle.2 DM was performed by start and the finish of a procedure were shown on ECG pressing on the carotid artery in the same manner as the strip as a note for the ensuing subsequent R-R interval CM initially. Once the emergency physician was able to calculation. Baseline R-R intervals were measured establish the rhythm of the carotid pulsation, the pressure before starting each technique. “Baseline mean R-R was released during the diastolic phase and reapplied interval” was calculated using the mean of 10 consecu- during the systolic phase. At least two augmented carotid tive R-R intervals and “baseline longest R-R interval” blood flow are generated, within the same total proce- was defined as the longest among the 10 intervals. Based dure time of 10 seconds. The CSM procedure was termi- on previous data, the maximum prolongation of the R-R nated if palpitation, arrhythmia, neurologic symptoms or interval was observed promptly after constant pressure signs, giddiness or syncopal attack was observed.
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