funky situation + cardizem = eep!

Okay, I couldn't figure this patient out. He wasn't my patient and I hadn't even read his H&P. Background: week from hell, third night on understaffed tele unit, me and another nurse who worked all 3 nights together, same unit. I'm in charge and it's bad if I haven't read the documents on any patients other than mine.

Ok so this guy came in first night with ... I wanna say he was a chest painer with ETOH issues, tranxene protocol and watch him. Second night he's had a cardiology consult and echo showed a floppy leaflet in his mitral valve. Still on tranxene protocol. Skinny little dude, almost cachectic, good affect, reminds me of a parkinson's patient because I always find him in the same arms-drawn-up positon.

Third night he's prepped for cardiac cath and consult CT surgery on whether he's a candidate to fix that valve. At 0430 heart rate shoots up to 170's and goes down to 120's. He was getting up to weigh. No problem. But over the next half hour it just won't come back down, goes 120's to 160's and I can't tell if it's afib or what the heck it is. Until 0520-ish his blood pressure holds steady 90's systolic. Then it drops to 70's systolic and that took about ten to fifteen minutes. I'm hearing the same thing manually and it's kinda thready. He's alert, oriented, and telling us that the high heart rate is because he likes his nurses.

We know from house supervisor that his cardiologist on call is right in the middle of something dire, and the hospitalist says to leave him alone, and that "digoxin won't work." Ok. CT surgery sends their PA to see him, and I tell her what's going on. She orders a cardizem drip. We are sure this is what the cardiologist would have spat out, so I dicker with her over the bolus and the rate and she comes out with 10 mg bolus, start rate at 5 and use protocol.

While all this is going on, I've taken 4 people to the bathroom, taken a blood sugar, and hung an antibiotic on my patients. The patient's nurse hasn't had time to do squat; she just started a cardizem drip not an hour ago on one of her other a-fibbers. So she's behind. We have a brief conversation about his blood pressure and I say "hmm. Maybe it'll drop his rate and that'll help the BP go up, and maybe we can get fluids in him fast enough if it bottoms him out, before he dies." Anyhow it doesn't seem like a good idea to let him go any longer with that ridiculous heart rate.

So I gave the bolus, slowly, start the drip, and turn it off about two minutes later d/t a blood pressure of 60/50. I could not believe my ears! The heart rate dropped to 80's but stayed irregular, the patient was still arousable. I really thought dropping the rate would help the cardiac output and raise the blood pressure; I'm sure the PA thought the same thing or she wouldn't have ordered cardizem in the first place. Oh. Almost forgot. He did get his AM Lopressor PO early prior to calling any docs. It didn't do squat.

Anyhow, he wound up getting 500 ml NS, blood pressure stabilized, still flirting with his nurses, 0700 comes around and the cardiologist who's gonna do the cath is informed and says it's all okay, he'll do the procedure. Nobody, that I know of, is questioning that what was done, was done, but simply how did we manage with two nurses. The patients were all ... interesting, needy, mean or just plain sick. AM shift thought it was so bad they called in another nurse after getting an idea of what was going on.

So I can't figure out what else, what other drug, should I have asked for? Do you ever "just leave it alone" when it's SVT on a CHF'er (kinda early CHF, but he diuresed well), with a floppy mitral valve? I wondered about low dose dopamine drip combined with IV verapamil... or digoxin... I'm trying to not call work in the middle of the night to find out what happened to this guy. Any ideas?