BRADYCARDIA

Complete COVER  ABCD A SWIFT_CHECK
Do not hesitate to treat as Cardiac Arrest  (1)
Ensure adequacy of oxygenation and ventilation (2)
If hypotensive (3)
     Inform the surgeon, stop retraction/stimulation
     Turn off vaporiser
     Crystalloid 500ml bolus and repeat if necessary
     Atropine 0.6mg IV for an adult; 0.012mg/kg IV for child
     Consider adrenaline slow IV bolus: 0.05 mg (adult); 0.001mg/kg (child)
        followed if necessary by an infusion of adrenaline:
            For adults, 1mg in 100ml burette starting at 60mls/hr (10 mcg/min)
            For children, 1 mg in 1000 ml, start at 0.1 mcg/kg/minute
Increase monitoring - ECG, arterial line, CVP
Consider external pacemaker (transvenous or transcutaneous)
 

Drugs (5)
     Inhalational agent overdose. Consider also suxamethonium, induction agents, neostigmine, and opioids. Check drugs
     given by surgeon.
Airway (2)
     Hypoventilation 
     Hypoxia
Vagal Reflexes (6)
     Cease stimulation
Regional Anaesthetic (7)
     Consider: Vasodilation, respiratory failure.
     Ensure: Volume loading, vasopressors (early adrenaline), airway support, left lateral displacement during pregnancy.
Surgical Factors (8)
     Consider: IVC compression, pneumoperitoneum, retractors position.
     Ensure: Surgeon aware.
Undetected Blood Loss (9)
     Improve IV access, fluid replacement, cross match.
Cardiac Event (4)
     Consider: Tension pneumothorax, haemothorax, tamponade, embolism (gas, amniotic or thrombus -
     sepsis, myocardial depression (from drugs, ischaemia, electrolytes, trauma.
Ensure: Review of appropriate pages in manual.

If the situation warrants:
Continue the adrenaline infusion, titrating against heart rate and blood pressure
Consider transvenous or transcutaneous pacing
Consider an urgent cardiology consult

NOTES:
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The figures reported here are based on an analysis of 265 of the first 4000 AIMS anaesthesia incidents. It was judged that the correct use of the algorithm would have led to an earlier recognition of the problem and/or better management in 4% of the 265 relevant incidents reported to AIMS.
(1) 25% presented as cardiac arrest.
(2) Airway problems were a factor in 19% of cases.
(3) 51% of cases were associated with hypotension.
(4) See above for the most common causes. Other important causes include myocardial events (particularly inferior ischaemia / infarction), anaphylaxis, pneumothorax and air/other embolism. One of these factors was responsible in 5% of cases. Multiple causes occurred in 22% of cases.
(5) Drugs were a factor in 40% of cases. Those most commonly implicated were inhalational agents (26%), opioids (16%), intravenous anaesthetics (14%) and suxamethonium (9%). Other drugs included muscle relaxants, anticholinesterases, metaraminol and phenytoin.
(6) Vagal reflexes were a factor in 14% of cases, usually following a surgical stimulus. The stimulus should be ceased and the problem usually resolves.
(7) Regional anaesthesia was a factor in 9% of cases.
(8) Surgical factors were present in 4% of cases.
(9) In addition to intraoperative losses, preoperative blood loss and occult losses (ie. into the chest cavity) were also reported. Hypovolaemia was a factor in 3% of cases.

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