Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Stable or unstable?Is the patient in cardiopulmonary arrest? Initiate ACLS ProtocolAssess the airway. Ensure the adequacy of oxygenation and ventilationAssess for hypotension. If patient is hypotensive, immediately communicate with the surgeon and examine the surgical field for possible causes. Then the following steps should be undertaken as necessary:Turn off the anesthetic vaporizerAdminister crystalloid bolus as appropriateAdminister atropine 0.01 mg/kgConsider epinephrine 10–50 μg IV bolusIf necessary, start epinephrine infusion at 2 μg/min and titrate as necessaryConsider intraoperative EKG, A-line, CVP monitoringConsider use of external pacemaker (transvenous or transcutaneous)Once patient is stabilized, or if stable, identify cause and treat: identify P waves and QRS complexes (see chapter 5):Each QRS is preceded by a P wave:Sinus bradycardia, sinus pauseNo P waves are visible:Irregular QRS rate: A-Fib with slow ventricular responseWide QRS: sinoatrial blockThere are more P waves than QRS complexes:PR getting longer, and then P without QRS: second-degree AV block Mobitz 1 (Wenckenbach)PR constant, occasional P without QRS: second-degree AV block Mobitz 2No relation between P and QRS: third-degree AV blockPossible causes:Airway issues:Hypoventilation? Increase respiratory rate and/or tidal volumeHypoxia? Increase FiO2 and/or PEEPHypotension:See Event belowConsider a cardiopulmonary event:Tension pneumothoraxHemothoraxTamponadeEmbolism—gas, amniotic, thrombus, fatSepsisMyocardial depression—drugs, ischemia, electrolytes, traumaPharmacological cause:Volatile agent overdose (or adequate dosing in susceptible patient), induction drugs, succinylcholine (especially if redosing), neostigmine, opioids. Identify drugs given by surgeon (e.g., vasoconstrictors)Vagal reflex:Discontinue stimulation; atropine if neededUndetected blood loss:Obtain additional IV access and replace fluids. Ensure cross-matched blood is available; transfuse as neededConsider other causes:Regional/neuraxial anesthetics: Bezold–Jarisch reflex causing vasodilation + bradycardia up to arrest. Ensure normovolemia; administer epinephrine IV boluses (start 10–50 μg, increase if needed)Surgical factors: IVC compression, retractor placement, pneumoperitoneum ++ Stable or unstable?Is the patient in cardiopulmonary arrest (e.g., ventricular fibrillation, pulseless ventricular tachycardia)? Initiate ACLS Protocol immediatelyWhat is the blood pressure?Hypertensive? (Consider hypertensive causes discussed in the section “Hypertension.”)Hypotensive?Reconfirm blood pressureTurn off vaporizersAdminister crystalloids appropriatelyDiagnose rhythm: See Chapters 5 and 16QRS duration <0.08 seconds:Regular: attempt vagal stimulus (carotid massage, ocular pressure, Valsalva, unless contraindicated):Each QRS is preceded by a P wave: SVTThere are more P waves than QRS complexes: atrial flutter or reentrant tachycardiaIrregular:There are no P waves: A-FibEach QRS is preceded by a P wave: reentrant tachycardiaQRS duration >0.12 seconds:Regular:P not visible, or dissociated from QRS: ventricular tachycardiaEach QRS is preceded by a P wave: SVT + BBBThere are more P waves than QRS complexes: atrial flutter + BBB or reentrant tachycardia + BBBIrregular:No P waves: A-Fib + BBBThere are more P waves than QRS complexes: reentrant tachycardia + BBBTreat:Poorly tolerated tachycardia (altered mental status, shock, chest pain), sinus or otherwise?Sinus tachycardia? ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.