II. Indication

  1. Evaluation of Cardioinhibitory Syncope

III. Contraindications

  1. Absolute Contraindications
    1. Myocardial Infarction
    2. Transient Ischemic Attack (in last 3 months)
    3. Cerebrovascular Accident (in last 3 months)
    4. Carotid ArteryOcclusion
    5. Ventricular Fibrillation history
    6. Ventricular Tachycardia history
    7. Previous adverse reaction to Carotid Sinus Massage
  2. Relative Contraindications
    1. Carotid Bruit
    2. Evaluate Carotid Bruit prior to massage
      1. Perform carotid Ultrasound
      2. Carotid Stenosis or atheroma suggests risk
      3. Obtain Informed Consent if massage performed

IV. Monitoring during carotid massage

  1. Parameters followed
    1. Continuous Electrocardiogram
    2. Blood Pressure
    3. Heart Rate
  2. Timing of monitoring
    1. Obtain baseline values prior to carotid massage

V. Precautions

  1. Never massage both carotids simultaneously
  2. Always ascertain both carotids as pulsatile in advance
  3. See Contraindications above
  4. Stop procedure for severe complications (see below)
  5. Confirm adequate equipment Needed
    1. Equipment for monitoring (see below)
    2. ACLS crash cart with Defibrillator

VI. Technique

  1. Patient positioning
    1. Test 1: Patient supine
    2. Test 2: Repeat test with patient at 60-70 degrees upright (allow equilibration for 5 minutes prior to massage)
      1. Indicated if Test 1 was non-diagnostic
  2. Initiate monitoring as above
  3. Identify carotid sinus location at midpoint between:
    1. Angle of Mandible
    2. Superior border of Thyroid cartilage
  4. Start with carotid sinus on right side
    1. Massage location firmly but gently
      1. Use same pressure that would indent tennis ball
      2. Do not apply so much pressure to occlude carotid
    2. Continue massage for 5 second period
    3. Record findings
      1. Symptoms of Syncope or Presyncope
      2. Mark massage period on Electrocardiogram
      3. Continue EKG until Heart Rate returns to baseline
      4. Record lowest systolic and diastolic Blood Pressure
        1. Occurs within 15 seconds of massage
  5. Repeat same procedure for other positions
    1. Repeat baseline monitoring values as above
    2. Repeat Carotid Sinus Massage of left side
    3. Repeat baseline monitoring values
  6. Observe patient in supine position for 10 minutes

VII. Complications (indications to stop procedure)

  1. Asystole longer than 3 seconds
    1. Administer precordial thump for prolonged Asystole
  2. Neurologic sequelae (Cerebral Infarction)
    1. Administer Aspirin
    2. Observe closely

VIII. Findings: Positive test

  1. See Cardioinhibitory Syncope
  2. Paroxysmal AV Block or Asystole 3 or more seconds
  3. Blood Pressure decreases from baseline
    1. Systolic Blood Pressure drops 50 mmHg or
    2. Diastolic Blood Pressure drops 30 mmHg
  4. Symptoms of Syncope or Presyncope with procedure

IX. References

  1. Degowin (1987) Diagnostic Exam, Macmillan, p. 837-8
  2. O'Shea (2001) J Am Geriatr Soc 49:236-7 [PubMed]

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