As you are attending to your patient's hypotension waiting for the anaesthetist to arrive, you note that her heart rate has fallen to 46 bpm. What should you do now? Provide rationales for you answer
Mrs Lucia Caruso is a 31-year-old woman who has been admitted into the postanaesthesia care unit (PACU) following a dilation and curette after having had an incomplete missed abortion (miscarriage). On arrival, Mrs Caruso has a size 3 laryngeal mask airway (LMA) in situ, and is unconscious and in a supine position. A disposable t-piece and oxygen, 6 litres per minute, are connected to the LMA and monitoring is connected.
You accept a full handover from the anaesthetist, who reports a fit and healthy patient and an uneventful procedure. An IV line is in situ in the back of the patient's left hand with a litre of Hartmann's solution running at an 8-hourly rate. You make your initial assessment and document the patient's vital signs as follows: airway clear, oxygen saturation 99%, respiratory rate 18 per minute, BP 130/90 mmHg (preoperative 120/80 mmHg) and heart rate regular at 74 bpm.
Five minutes after arrival, Mrs Caruso stirs and opens her eyes and you remove the LMA and place her on 6 litres of O2 via a Hudson mask. Now that the patient is conscious, you continue your observations, taking and recording her core temperature (using a tympanic ear thermometer) at 36.2°C and assessing the per vaginal (PV) loss, which is slight and bright.
You sit Mrs Caruso slightly head up to facilitate optimal ventilation. Mrs Caruso is understandably upset and so you comfort her. Her vital signs remain stable and so after 15 minutes you remove her oxygen and trial her on room air.
Mrs Caruso appears stable: SaO2 97% on room air, BP 115/85 mmHg, respirations 20 per minute and heart rate 70 bpm. No further PV loss is present and so you conclude that your patient is ready to be transported to the ward. You decide to record the next set of observations (due in 2 minutes) on the ward observation chart and then you will call the ward nurse to collect Mrs Caruso.
What will be an ideal response?
Answer:
Press the emergency bell. If a patient is suffering both a bradycardia and hypotension, they will have a significant drop in their cardiac output and will be compromised, requiring urgent medical attention.
Recalling the physiology of hypovolaemic shock, when the BP falls, the heart rate increases to compensate and to maintain cardiac output. When both the BP and the heart rate fall, there is no compensation, thus severe compromise to cardiac output may follow.
Follow the instructions from the medical staff, which may include:
administration of atropine (or similar anticholinergic)
increasing the rate of intravenous fluids.
Treatment will usually see a rapid recovery.
Close monitoring of the patient following this situation will be required.
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