bradycardia with nitro drip?

  1. 0
    Nurse of 2 weeks experience on telemetry floor. Pt. transferred from smaller hospital with decompensated hf, scant information provided. Upon admission orders written for nitro drip and lasix drip. Stable bp's/hr's ( slightly over 100 sbp/hr 60-70) on nitro drip while titrating up for two hours, then no change for two hours as desired sbp achieved. Lasix drip without titration. Output not increased. Four hours in, pressure suddenly 70's systolic, hr 50's. Drop happens as titrating off nitro gtt as provider now thinks pt. septic and wants it d/c'd.
    No other cardiac meds (beta/ace/arb/etc.) on board due to nonadminister prior to transfer, pharmacy issues, and now blood pressure issues.
    Why would heart rate go down as blood pressure does? Without a whole host of additional information I understand that no conclusions can be drawn, but my undeveloped gut would say hr should attempt to compensate.
    Thanks for any input as I learn all day at work and when my head clears at home come up with more questions.
  2. 10 Comments so far...

  3. 0
    Was the patient sleeping? What was the rhythm?
  4. 0
    Sink a pacing swan and see where you're at.
  5. 1
    Lasix gtt...what's the potassium?

    Low or high K+ can cause bradycardia (even without adequate output), while the NTG lowered the BP. There's a disaster waiting to happen.

    Any thoughts?
    turnforthenurseRN likes this.
  6. 1
    Change of rhythm with loss of AV-synchrony leading to cardiogenic shock perhaps? Sudden change suggests acute event... Could be a septic problem with a failing heart that is simply no longer capable of compensating for the decrease in preload.
    turnforthenurseRN likes this.
  7. 1
    I'm also wondering if the pts intrinsic rate prior to the hospital admission is in the 50s. Then, the acutely low BP is d/t the nitro and problem solved.

    So why wouldn't the heart compensate for a low BP? In some elderly, especially those with a low EF%, this compensation takes some time bc the heart isn't as "young" anymore and is not as resilient and may not have a lot of reserve capacity.
    turnforthenurseRN likes this.
  8. 0
    Thank you all for the input. Assigned to same pt. today. Pt. is 1. septic. 2. EF of < 15% 3. K was unknown, pt. was given k prior to starting lasix to offset anticipated losses. So, it seems as though as the posters thought, it seemed to be a mix of systemic infection and a tired heart. Rate on admission was 60s-70s sinus for the poster who asked, unchanged during drip titration, with drop into 50's sinus. My preceptor of many years has a bad feeling, so I don't know what will be present Monday morning.
    Thanks all as I start to learn what I need to learn.
  9. 2
    Bradycardia in septic shock is usually an ominous sign, signifies circulatory collapse...time for invasive monitoring and CICU transfer only hours before they code....keep us updated
    GrinchyRN and Creamsoda like this.
  10. 0
    Hello all. Thanks for the responses. I do not know the full story, aside from the fact the pt. remained on the floor for another week with dx of endocarditis. Did run into family member of pt. who said that she was there as pt. was being transferred back to smaller hospital in a more stable condition. Did not get into nitty-gritty as orientation has been leaving me with a feeling of having my butt kicked. Still plan to follow up with a cns/cardio np re: original question. On a side note, got my first hug from a family member and it made some of a rough week better.
  11. 0
    however it is been too long for answering, but I think this will be helpfull for you to promot critical thinking.
    HF classify as compensated HF and decompensated HF. at decom.. hF, the sympatic system and renin angiotansion can not compensate the pump failure situation. for example, in normal situation when SBP fall down, HR increase for compensate decline of BP. but in end stage of HF because of heart muscle weakness, HR decrease same as your pation state.
    if more information needed, read Cardiac Nursing (woods)


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