heart rate 40 ,SBP 60, for over an hour - page 2

by brownbook

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?Healthy?, 60ish year old male out patient surgery patient had a history of "vasovagal" episodes. Went from HR 70's, SBP 120's, to HR 38 - 40, SBP 60's. Patient said he was okay, just tired, he responded appropriately to me the... Read More


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    Bedrest!! Dang I hate autocorrect!!!! LOL!!
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    I used to work in a cardiovascular outpatient unit where one of the procedures done called a Tilt Table Test. We would use the tilt table to stand them up about 70 degrees. The indication for the test is syncope and usually, the obvious causes had been ruled out. Basically, the patient stands for up to 45 minutes. The patient is on the monitor and the NIBP is set for every 2 minutes, and if there have been no significant symptoms at 30 minutes, we would give the pt. 0.4 mg of nitro SL (provided the doctor was either in the room or at the nurse station). The BP would then be checked at least every minute, although most of us just put it in "stat" mode. Many times we would see long pauses (up to 2 or 3 screens, sometimes). Sometimes patients would pass out and we'd only see a drop in BP but no significant drop in HR.
    At any time during the test, if the pt passed out, we'd put the table down to supine and the test was done. If they didn't pass out within 15 minutes of the nitro, we laid them down and the test was considered negative. I believe the doctors said that 25% of the time, a pt with vaso-vagal syncope would test negative.
    The point I'm trying to make is we would cause the patient to "vagal" then lay them down and give them half a liter of 0.45 NS. And they were usually ready to go home in about 45 minutes to an hr. I'd also give them water &/or juice to drink and offer them some food. In 10 yrs doing the test, I think I gave atropine twice.
    The patient would feel better after the IVF and even more so after eating.
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    Sounds like you did the right thing. IVF's are a solid choice, and continuously monitoring, which it sounded like you did. The only thing that comes to mind is the documentation. "Physician notified re: bradycardia and hypotension. MD aware, no new orders given. Continuing to monitor the patient." Also as was mentioned, asking the MD if they have considered an EP consultation is a great idea.
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    Did your BP monitor tell you the MAP? The patient could have been fairly asymptomatic if his MAP was still 60 or above. MAP is generally an important reading in ICU, but is often forgotten about on other units. I've gotten several patient on pressure supporting meds due to telling the MD that I calculated the MAP and it was less than 60 and I was concerned that even if the patient was asymptomatic at the time, a prolonged time of a MAP less than 60 means vital organs are not getting perfused.
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    As someone with vasovagal syncope, this is an interesting thread to read! My first episode happened at home. I thought I was having a heart attack. Thank goodness my husband was home and called 911. Paramedics came and never could get my pulse or BP since both were extremely low. It wasn't until the ambulance got me to the ER that they were able to get my VS. I was completely out of it, lost bladder control, and remember feeling like I was floating outside my body watching what was going on. After 2 days in the hospital and all sorts of tests, I was cleared by my cardiologist and neurologist. I periodically have "episodes" but I've learned to recognize the signs and do what my neurologist told me to do: lay down and put my feet up no matter where I am. I've done that in Target a few times (their lights will sometime trigger an episode) as well as the mall and the grocery store.
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    Quote from BuckRN
    Did your BP monitor tell you the MAP? The patient could have been fairly asymptomatic if his MAP was still 60 or above. MAP is generally an important reading in ICU, but is often forgotten about on other units. I've gotten several patient on pressure supporting meds due to telling the MD that I calculated the MAP and it was less than 60 and I was concerned that even if the patient was asymptomatic at the time, a prolonged time of a MAP less than 60 means vital organs are not getting perfused.

    Good point. Honestly, MAP isn't really emphasized working on my unit (med/surg)..good to know though... thanks for bringing it up. I usually just ignore that number!


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