Published Jan 12, 2020
asystolesurgery
2 Posts
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.
Christopher McDowell, EMT-P
4 Posts
In my 10 years I've never seen a patient vagal into asystole or an idioventricular rhythm. A very low sinus brady sure, pretty common, but never into an idioventricular. I think your probably right that this patient should have been sent for a cardiac workup.
MunoRN, RN
8,058 Posts
This is usually attributed to "blood injury phobia" with venipuncture and cardiovascular collapse including periods of asystole is not uncommon, but in theory at least should always be self-limiting.
On a related note, the term "asystole" is commonly used to describe a distinctly different cardiac event than what occurs in a normal rhythm, but in reality if your heart rate is 60 beats per minute then you are in asystole 60 times a minute, so the difference between severe bradycardia and asystole is more semantics than a physiologically different event.
Since the mechanisms that cause syncope with venipuncture are somatic, they rely on a certain level of consciousness, once the level of consciousness drops sufficiently the mechanism is halted, which then allows for a return to normal cardiovascular function. Apparently the amount of time this takes is around 8 seconds of asystole: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531772/
amoLucia
7,736 Posts
To Munro - TY for your info. Been retired 10 years now, but still enjoy learning something new every day or so.
JKL33
6,952 Posts
Didn't have time to keep looking into this yesterday but I found this older abstract that sounded interesting -
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1540-8159.2006.00394.x
"nursy", RN
289 Posts
I would guess that the majority of vasovagal responses are not caught on an EKG monitor, and so it would be hard to know just how many end up with any amount of asystole.
guest1139088
19 Posts
I think you responded like I would have, but that patient needs a thorough workup before going to elective surgery.
murseman24, MSN, CRNA
316 Posts
Of course the surgeon said that it was safe to proceed ?. Did anesthesia let the case go? I think you did fine, the CRNA was there so technically it was really up to them. Just ACLS when things go that far down hill.
nursej22, MSN, RN
4,431 Posts
Working in a heart cath recovery unit, had a patient recovering from and EP study who vagaled and went into 6 seconds of asystole after swallowing Percocet. We called a code but had no time to give Atropine. We lowered the head of the stretcher and he woke up with a shake and shout. EP doc discharged him home after having him up and walking about for 15 minutes.
Another case vagaled during an arterial sheath pull following a diagnostic cath. We pushed atropine but the patient went into asystole of about 5 or six seconds. She woke up just before the first compression. She stayed overnight without incident.
PNW-RN, BSN
Only time I experienced was pulling a femoral sheath, put brady down into the 30s but was self limiting.
canoehead, BSN, RN
6,901 Posts
I've had several patients pass out from vagal reactions. One passed out in the triage chair, went grey, so I lowered him to the floor and couldn't get a pulse. Called a code, but once he was on the floor his eyes started to flicker and he came to rather quickly. I assume he had just a very long pause...not cool!