ACLS in action
Story from an AMRI certified professional
11/8/2011 | Vincent Vilasi, MD, Anesthesiologist
“We had a previously healthy patient in her 30's undergoing a laparoscopic procedure under general anesthesia. I was paged stat to the operating room because the patient had developed a narrow complex tachycardia and hypotension. After a quick assessment, I did carotid sinus massage. The patient returned to sinus rhythm within seconds and the blood pressure returned to normal on the following cycle. Deep respect and awe followed. ;)
No further incident occurred in the OR or recovery room and the patient was notified about her condition and told to follow up with her internist or family doctor.”
-Vincent Vilasi, MD, Anesthesiologist
AMRI’s response - The report regarding the sudden arrhythmia which occurred during general anesthesia demonstrates the benefit of having clear understanding of the patient and differential causes and therapy options. The reporting practitioner, knowing the young woman’s negative past medical history, knew that by mechanism, she had developed some form of SVT.
There was multiple options available regarding intervention. Adenosine; calcium or beta blockers; synchronized cardioversion could all be possibilities. This anesthesiologist elected a relatively safe, non-dramatic initial approach: a vagal maneuver. Considering that the statistically most common mechanism of narrow regular QRS SVT in young, healthy patients is A-V nodal re-entry. All of the pharmacological agents mentioned would work at the A-V node. However, so does manually increasing vagal tone.
There are some concerns regarding risks of carotid massage, however, in a 30 year old patient, they are generally non-existent. In the event that this patient had been refractory to the vagal maneuver and continued to be hypotensive, low-energy synchronized cardioversion would be a reasonable next step.
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