emd123 --- you make a few erroneous assumptions
1) that when a patient is not feeling well while prone during a procedure: it is necessarily a vagal response. I have had 2 patients with symptomatic bradycardia - one of which I had to trans-cutaneously pace and transport to the ER and ended up needing a pacemaker. I have had one patient who had an MI (we had held plavix for 7 days for a cervical stim trial) on the table, and while he didn't become unresponsive, he acted like a vagal (nausea, clammy, thready pulse).... I have had another patient who (unbeknownst to me was hyper-ventilating) become unresponsive and then started having these weird hand/foot contractures (ended up being severely hypokalemic)... if you do enough procedures you will see a tiny bit of everything.
2) these patients are already horizontal and are passing out --- so maybe lying horizontal is not enough to reverse a vagal response
3) vagal responses are not all the same: some times it can extremely transient, in other cases it can last for a while... I had one guy who vagal'ed, we cancelled the procedure, brought him to the recovery area on a stretcher and I couldn't discharge him home for 3 hours, because every time he would sit up he would pass out again (i eventually gave him some ephedrine)...
4) how does it look legally: guy passes out supine on your table - you just continue doing your procedure - guy remains unresponsive and doesn't do the "automatic emd123 wake-up", how are you going to explain that in court when the RN in the room will testify that you didn't do anything...
now i will agree that IV fluids is probably not going to do that much - primarily because volume won't be that much through a small gauge needle... on the flip side, if the patient doesn't perk up w/ stimulation, supine/legs elevated, they automatically get an IV.... why? because I am an anesthesiologist - and part of my training is to be ready for plan B, plan C and plan D - instead of waiting for things to spiral out of control...
I see your point, but I think you're misreading some assumptions into what I wrote:
1. I never assumed that "
when a patient is not feeling well while prone during a procedure: it is necessarily a vagal response".
Let me be clear: I think Sweetalkr did the right thing in this situation. It sounds like he did a good job responding to this complication, primarily because it wasn't clear at the time whether or not it was a benign vagal episode. Which is why I wrote,
"if you're not sure that what you're seeing is a vagal episode, you go down the resuscitation pathway until certain the episode is benign." Which is what Sweetalkr did, correctly so. I think that pretty clearly states that what appears vagal may not always be clear and you go down the resuscitation pathway until certain the episode is benign. And if it doesn't, let me acknowledge, you're right, not everything that appears to be benign/vagal will turn out to be benign and vagal. Especially during a cervical with local.
But in defense of my post, my post was about vagal episodes. An
MI is not a vagal episode. I never said treat ST elevation MIs like vagal episodes. Neither my post nor Sweetalkr's referred to MI's. I know how to treat MI's. That's a whole different thread. Sweetalkr's was about vagal vs. intrathecal injection of ropivicaine/dex.
Persistent symptomatic bradycardia, is not a vagal episode.
Also, people that have panic attacks, hyperventilate, blow their CO2 down which can cause carpopedal spasms from transient hypokalemia which is also self limited, and very common. UNLESS, they started out hypokalemic to begin with, then you can have a more prolonged situation, like you had; likely a transient drop in potassium on top of a pre-existing low K+. Of course, we don't routinely do pre-procedure labs, like in the OR, so how would you know?
2.
"these patients are already horizontal and are passing out --- so maybe lying horizontal is not enough to reverse a vagal response"
You're right, it's not enough, like I said, 2 things are required: "treatment of the episode is 'head down'
and a few minutes of time". It takes a few minutes. By definition, if its prolonged, you have a some underlying pathology that's mimicking a neurocardiogenic (vagal) episode. Bradycardic for 30 seconds? Probably vagal. Bradycardic for 15 min requiring transcutneous pacing, atropine and pressors? Not vagal. When you're bringing out the pacer pads, put on the full court press. Loss of consciousness during cervical epidural with Ropi (yikes), may not be "just vagal".
Again, my post was about vagal episodes, not the entirety what can cause a patient to crash.
3.
"I couldn't discharge him home for 3 hours, because every time he would sit up he would pass out again (i eventually gave him some ephedrine)"
This is interesting. I would say again, by definition, not a vagal episode if it lasted 3 hr and required ephedrine. It would be interesting if you could get some follow up here and post what they found out during his work up.
I would suspect there may have been some underlying hypovolemia, anemia, orthostatic hypotension, electrolyte imbalance, occult infection or something else leading to 3 hours of persistent orthostatic symptoms. The procedure may have tipped him over the edge.
4. "
how does it look legally: guy passes out supine on your table - you just continue doing your procedure - guy remains unresponsive and doesn't do the 'automatic emd123 wake-up', how are you going to explain that in court when the RN in the room will testify that you didn't do anything"
If I witnessed a patient truly having a vagal episode, which I have countless times, I would have no trouble defending myself legally because there would be no lawsuit.
If an otherwise healthy patient passes out on my table
before a procedure, during a panic attack associated with classic hyperventilation and carpalpedal spasms, would I do "nothing"? No. I'd do almost nothing. Like I said, I'd lay the patient down and observe for about 60 seconds. A little sternal rub, and time to start moaning groaning and to wake up. During or after a cervical? Different story. Local given in the cervical (which I don't do), a whole other story.
The procedure I happened to be referring to was suturing. When people pass out during benign procedures like this, giving blood, etc, its
almost always vagal and benign. I acknowledged that in the setting of a cervical epidural things are much different. Like I said,
"
in the Interventional Pain world now, it does ratchet the sphincter tone up a few notches when all this occurs during and after a cervical epidural, that's for sure"
Let me be clear, I think Sweetalkr did the absolute right thing, like I said:
"..
.if you're not sure that what you're seeing is a vagal episode, you go down the resuscitation pathway until certain the episode is benign."
But, I'll stand by the fact that if someone truly vagals, and you're certain that they only vagaled, yes, you do absolutely (almost) nothing. At the red cross, when people faint at the sight of their own blood, what do the little old lady volunteers do? Lay down, juice, cookies, home in 30 minutes if able to walk across the room without being dizzy.
Not all of our heroic treatments are benign either. Intubation can lead to aspiration. Pressors can trigger tachycardia and cardiac ischemia in patients prone to it. Being on a vent can lead to nasty hospital acquired pneumonia and sepsis.
I may be a fellow when it comes to Interventional Pain, but this stuff I know inside and out, in my sleep.
