Post-op bradycardia

Question 1

A 67 year old male had a urological procedure yesterday and you are asked to see him because his heart rate is persistently below 60/min. He has known prostate cancer, gout, hypertension and coronary disease.

Answer 1

Impression
Bradycardia indicates an SA node dysfunction or disorder of the conduction system, otherwise consider if physiological.

Causes to consider

• Medications: anaesthesia, ß-blockers, CCBs,
• Cardiac: ACS, arrhythmia, valvular disease, heart block
• Other: electrolyte derangement (hyperkalaemia, acidaemia)

Goals

• Main differentiation to make is whether symptomatic vs asymptomatic, call for senior help and start resus if symptomatic
• Hx/Ex/Ix to rule out Red Flag causes of this presentation
• Definitive management according to underlying cause

Question 2

Post-op bradycardia - Assessment

Answer 2

Assessment
A - as per
B - SP02 monitoring, supplemental as required
C - serial ECG, IV access, HR/BP monitoring. Assess pulses, auscultate chesttranscutaneous pacing on if unstable. Initial bloods (VBG, serial trops, BNP, FBC, UEC).

• call for senior help if HD unstable

Question 3

Post-op bradycardia - History

Answer 3

History

• op report notes, ?Bradycardia before/during surgery, anaesthetic agent used, any operative complications
• Sx: chest pain, dizziness, palpitations, LOC, visual changes, dyspnoea, SOB
• Medications: beta blockers, other anti-arrhythmics, anaesthetic agents
• PMHx: Infective hx,
• CVD risk factors: previous stroke/MI, diabetes, HTN, etc
• SNAP

Question 4

Ex

Answer 4

Examination

• general appearance + vitals
• cardiac examination: cap refill, peripheral oedema, pulse rate, heart sounds

Question 5

Ix

Answer 5

Ix

• Bedside: ECG (ACS, sick sinus, etc), VBG
• Bloods: FBC, trops, UEC, BNP, CMP (for magnesium)
• Imaging: TTE/TOE for structural heart disease

Question 6

Mx

Answer 6

Managment
Definitive
Stable
- supportive
- cardiac review
- treat underlying cause
- medications review for drug contributions

Unstable
ACS/Bradycardia pathway
- HR<40/ additional symptoms then MERT
- ICU/CCU help or admission
- IV atropine (0.5mg bolus) +/- Dopamine +/- isoprenaline/adrenaline (vasopressor support)
- transcutaneous pacing
Definitive
- ultimately, pacemaker insertion +/- defib as required