Termination of paroxysmal supraventricular tachycardia by digital rectal massage

The alternative vagal maneuver; converting atrioventricular nodal re-entrant tachycardia by a rectal thermometer

Vagal maneuvers are techniques used to increase parasympathetic tone, particularly useful in the management of hemodynamically stable supraventricular tachycardias. If ineffective, adenosine can be attempted. We present a patient with atrioventricular nodal re-entrant tachycardia (AVNRT), who could not effectively perform Valsalva maneuvers and had contraindications for carotid massage and adenosine administration, that converted into sinus rhythm by using a rectal thermometer. This maneuver was reproduced on various occasions. We suggest that rectal vagal maneuver may provide an additional therapeutic modality for selected patients with AVNRT.

The wonders of the Wanderer

Vagus is Latin for wandering, and the vagus nerve fully deserves this name due to its extensive distribution through the body. Indeed, one of the lines of the song that accompanied the 2012 G. L. Brown Prize Lecture exaggerates this diversity, 'My function's almost anythin', and vagus is my name'. Alteration of vagal activity was first investigated in the 1880s as a treatment for epilepsy, and vagus nerve stimulation is now an approved treatment for refractory epilepsy and depression in the USA, despite an incomplete understanding of the mechanisms involved. Vagus nerve stimulation could be beneficial in many other conditions, including heart failure, tinnitus, chronic hiccups, Alzheimer's disease and inflammatory diseases. Inhibition of vagal activity could also be beneficial in some conditions, e.g. reducing activation of vagal respiratory afferents to treat chronic cough. This review discusses evidence underlying some current and potential therapeutic applications of vagal modulation, illustrating the wonders of the Wanderer.

Instantly Converting Atrial Fibrillation into Sinus Rhythm by a Digital Rectal Exam on a 29-year-Old Male

Vagal maneuvers cause increase in vagal tone, which has been shown to slow many types supraventricular tachycardia, such as atrial fibrillation (AF). However, the conversion of AF to sinus rhythm is usually not associated with vagal manuvers. Thus, AF is classically treated with medication and electrical cardioversion. Here, we present a 29-year-old male with no cardiovascular history and a low atherosclerotic risk profile who developed AF which converted into sinus rhythm immediately after a digital rectal exam. The patient remained asymptomatic after a 3-month follow-up. This implies that the digital rectal exam can be considered as an additional attempt to convert AF to sinus rhythm in AF patients.

Defecation-induced bronchospasm

Acute asthma exacerbations are common. Patients with asthma experience symptoms in response to a wide variety of stimuli, and identifying the precipitating cause may be useful in guiding treatment and preventing future attacks. A case of asthma exacerbation occurring during multiple defecations is reported. Abnormal parasympathetic tone has been implicated in the pathogenesis of certain types of asthma, and defecation can be associated with increased parasympathetic tone. This patient's pattern of defecation-related asthma exacerbations responded to prophylactic anticholinergic medication.

Termination of intractable hiccups with digital rectal massage

A 60-year-old man with acute pancreatitis developed persistent hiccups after insertion of a nasogastric tube. Removal of the latter did not terminate the hiccups which had also been treated with different drugs, and several manoeuvres were attempted, but with no success. Digital rectal massage was then performed resulting in abrupt cessation of the hiccups. Recurrence of the hiccups occurred several hours later, and again, they were terminated immediately with digital rectal massage. No other recurrences were observed. This is the second reported case associating cessation of intractable hiccups with digital rectal massage. We suggest that this manoeuvre should be considered in cases of intractable hiccups before proceeding with pharmacological agents.

Ventricular fibrillation during rectal examination

The case of a 74-year-old man who developed ventricular fibrillation during a digital rectal examination is presented. The patient was subsequently resuscitated and developed cardiac enzyme elevation without ECG changes, indicating a nontransmural myocardial infarction. Although controlled studies have not shown any ill effects of rectal examination in patients with acute myocardial infarction, there have been multiple case reports of bradycardia, ectopy, and ventricular arrhythmias resulting from rectal examination. The postulated etiology of the ectopy is twofold; increased vagal tone from rectal parasympathetic innervation or increased sympathetic tone from anxiety-stimulated catecholamine release. Rectal examination is definitely indicated in a subset of patients including those with gastrointestinal or genitourinary complaints, unexplained hypotension or anemia, trauma, and neurological deficits, and those who will receive anticoagulation or thrombolytic therapy. In the remaining patients, the decision must be made on a case-by-case basis. Awareness of and precautions for possible ill effects of the examination are prudent.

MAST application in the treatment of paroxysmal supraventricular tachycardia in a child

A case of paroxysmal supraventricular tachycardia (PSVT) in a child with successful termination of the arrhythmia by military antishock trouser (MAST) application is described. The use of MAST application in terminating PSVT in adults has been previously reported. Ours is the first such case reported using this method in the therapy of PSVT in children. Our report suggests that MAST application may be another maneuver to add to those vagal maneuvers known to be of benefit in the termination of PSVT in children as well as in adults.