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A carotid massage, also known as carotid sinus massage or CSM, is a medical technique utilized to slow down a dangerously rapid heartbeat in patients or to diagnose specific heart rhythm irregularities. Healthcare professionals may also employ a CSM to investigate a patient’s fluctuating blood pressure and other potentially serious symptoms. To perform a carotid massage, you’ll need to massage the area at the base of the patient’s neck, where the carotid artery enters the head. The carotid artery carries blood to the brain, and an improperly performed CSM can lead to severe health consequences, especially in elderly patients. Do not attempt this maneuver on yourself or another individual unless you are a qualified physician.
Steps
Preparing the Patient
Instruct the patient to lie on their back. For safety reasons, a CSM should be conducted first with the patient supine (lying flat on the back) and then sitting up with at least 5 minutes of rest in between. After performing the maneuver in both positions, observe the patient for 10 minutes while they remain lying down. If you’re in a medical setting, have the patient lie on an examination bed. If performing the CSM at home, ask the patient to lie on a couch or bed.
- It’s crucial for the patient to be lying down to prevent lightheadedness or loss of consciousness resulting from the CSM.
Position an electrocardiograph (ECG) on the patient. This medical device monitors the heart's electrical activity during the carotid sinus massage (CSM). Since CSM is primarily diagnostic, the ECG is essential for monitoring heart activity. Discontinue CSM immediately if the ECG indicates asystole (heart stoppage) for more than 3 seconds. Additionally, an ECG aids in diagnosing carotid sinus syndrome.
- Even when performing CSM to alleviate a patient's excessively rapid heartbeat (supraventricular tachycardia, or SVT), always monitor heart activity using an ECG. Employ an ECG for every CSM procedure.
Monitor the patient’s blood pressure before, during, and after the procedure using continuous blood pressure and heart rate monitoring. This data can provide insights into the cause of rhythm abnormalities and is also crucial for safety purposes.
- Once the patient is in a supine position, and you've applied the ECG and initiated blood pressure monitoring, wait five minutes before commencing the procedure. This allows the patient’s heart rate to stabilize, enabling accurate baseline blood pressure and heart rate measurements.
Conducting the Massage
Locate the carotid sinus massage site. There are two carotid sinuses, and each requires a CSM. Find the mid-point of the patient’s neck (near the Adam's apple) and the angle of their jaw. Trace your finger around the side of the patient’s neck until it's directly below the angle of their jaw. This is the carotid sinus.
- The angle of the jaw is where the jawbone bends, approximately 4 inches (10 centimeters) back from the chin's tip.
- The second carotid sinus is in the same position on the opposite side of the patient's neck.
Massage the right carotid sinus for 5–10 seconds. Begin the CSM on the right side of the patient’s neck. Apply firm pressure to the carotid sinus massage site. Using a circular motion, massage the carotid sinus for 5–10 seconds.
- Avoid excessive pressure to prevent reducing oxygen flow to the brain. Use a pressure equivalent to indenting the surface of a tennis ball.
Proceed to massage the patient’s left carotid sinus. After conducting the carotid massage on the right side of the patient’s neck, repeat the procedure on the left carotid sinus. Massage in a circular motion for 5–10 seconds.
Instruct the patient to remain still for 10 minutes. After completing the CSM, the patient may experience slight lightheadedness or dizziness. Advise them to continue lying supine for another 10 minutes. This allows their heart rate to normalize (if it was initially elevated) and ensures adequate oxygenation to the brain.
Ending the Massage
Terminate the CSM if the ECG indicates asystole. Asystole, a severe form of cardiac arrest possibly induced by the CSM, warrants immediate cessation of the maneuver. If the ECG indicates absence of electrical activity and ventricular contraction for more than 3 seconds, discontinue the procedure without delay.
- If the patient remains in cardiac arrest post-cessation of CSM, consider initiating life-saving measures like a precordial thump. Avoid defibrillation unless the ECG indicates a shockable rhythm such as ventricular fibrillation or ventricular tachycardia, as asystole does not respond to defibrillation.
End the CSM if the patient loses consciousness. If the patient faints during CSM administration, even momentarily, halt the massage. Record the occurrence of syncope (loss of consciousness) or pre-syncope (dizziness or lightheadedness preceding unconsciousness), and inquire if the experienced symptoms resemble their typical ones, especially if CSM is for diagnostic purposes.
- If CSM is performed for diagnosis, inquire whether the lightheadedness or fainting matches their usual symptoms.
If any neurological complications, such as a stroke, occur, cease the CSM immediately. In case of a stroke, administer aspirin (if not contraindicated) and closely monitor the patient.
Avoid performing CSM on patients with carotid sinus hypersensitivity. Patients with carotid sinus hypersensitivity (CSH) are highly sensitive to pressure on their carotid sinus. This condition predominantly affects men over 50, although women in the same age group can also experience CSH. Administering CSM to a patient with CSH can lead to cardiac arrest or other severe heart and blood pressure complications.
- Enquire if the patient has been diagnosed with CSH by a physician or if they have previously experienced negative reactions to—or lost consciousness during—a carotid sinus massage.
Moreover, refrain from performing CSM on patients with any of the following conditions:
- Recent Myocardial Infarction
- Transient Ischemic Attack within the past 3 months
- Cerebrovascular Accident within the past 3 months
- History of Ventricular Fibrillation
- History of Ventricular Tachycardia
- Carotid Artery Occlusion
- Previous adverse reaction to CSM
- If a patient presents with a carotid bruit, conduct a carotid ultrasound first to assess for stenosis.
Recommendations
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The Carotid Artery Massage is one of several medical procedures known as “Vagal maneuvers.” Vagal maneuvers stimulate the vagus nerve (located along the side of the head) to release chemicals that slow a patient’s heart rate.
Important Notes
- Do not conduct a CSM in a primary care medical office unless it is equipped with full resuscitation facilities.
- Avoid performing CSM on both carotid arteries simultaneously.
- Always ensure the availability of an ACLS crash cart (including a defibrillator) and monitoring equipment (ECG, blood pressure, and heart rate).
- The massage can induce a stroke in elderly patients due to reduced oxygen supply to the brain. Therefore, CSM should only be conducted in a medical facility equipped with resuscitation facilities.
