Severe vasovagal reaction

[asystolesurgery]

Hi guys, I'm pretty new to allnurses so let me know if I need to change something. For reference, I do pre-op and PACU and circulate, depending on the case. I work in elective ambulatory surgery.

I recently had a healthy, older adolescent patient come in for a procedure. His pre-op assessment and vitals were flawless. NSR in the 70s. No medical history and no daily meds. No history of vasovagal reactions.

I start his IV in the AC with no problems whatsoever - clean stick. He says he is feeling dizzy, so I start reclining his chair/elevating his legs while reassuring him that this happens sometimes and it's okay. I'm looking at him as he turns white and passes out. I look at the monitor, which just shows a HR of "<30" and the rhythm is agonal and slowing. The CRNA was next to me but facing away and drawing up meds, so I whack him on the back. He turns to look at the monitor just as the rhythm falls to asystole.

He says "oh ***" and turns to draw up emergency meds while I reach for the lever to drop the chair to supine for compressions. Then we get a beat, and another. The patient came back in a slow idioventricular/junctional (low 30s at first). The CRNA slammed some Robinul. The surgeon arrives at this point as I'd sent for him as the patient was crashing. The patient comes around, announces he is "tired" but is responsive. He converted back to NSR in the 60s within a minute or two, his blood pressure was WNL, and everything was okay again. Looking at the strips that automatically printed, he was in an agonal rhythm for probably 20 seconds and went asystolic for 8 seconds.

What I'm struggling with is: 1) How common is it for a patient to vagal down to ASYSTOLE? 2) I don't feel that my response was the best. How can I improve? 3) The surgeon looked at the ECG and decided that since the patient had normal vitals and there were no ST changes, etc. we were safe to proceed. I feel really weird about this because it was an elective surgery, the patient just had a significant cardiac event, and I think he should have been referred for a workup before we put him under for a 1.5 hour elective procedure.

I appreciate any input here. Obviously in an elective ambulatory setting we strive to be prepared for but do not really expect emergencies like this. Especially in young healthy patients. I'm also a fairly new nurse so it's not like I have years of experience to draw from.

Thanks in advance.

[FurBabyMom, MSN, RN]

If it really truly was vasovagal, then it was not truly cardiac in the sense of an MI or something like that. What makes you think this is a cardiac situation? Or that a workup was warranted? Did your patient watch you place the IV or see any of the items which may have had blood on them? Seeing blood is a very common trigger of a vasovagal reaction.

I think it's totally up to the surgeon and anesthesia team to determine if it is safe to proceed. My surgeon and anesthesia colleagues would have probably recommended proceeding too. At the same time, I work in a Level I trauma center, so we see it all...even our elective patients are very different than those in the surgery center world.

I would recommend reviewing your facilities policy or procedures for those situations. Follow up with your charge nurse or manager about how things could have been handled differently? Maybe discuss with the surgeon or anesthesia team as a follow up to understand why they wanted to proceed.

[RobtheORNurse]

It happens, chalk it up as a learning experience. Know how to treat it, elevate secure airway, elevate the legs above the heart provide care as indicated.