V tach leading to an MI

Caffeine_IV · Feb 7, 2014

Whoa! I need to jump in here. You do realize that saying "the doctor told me" is not absolution from responsibility in COURT OF LAW. Because the doctor does not "want to be disturbed" at night-will not absolve you of responsibility. The FIRST thing that MD will do especially without a written signed order is say...."THAT is NOT what I meant!" and the facility will not have a "policy" that states this as procedure for "emergent" arrhythmia notification (believe me there won't be) and the nurse will be sold down the river! Even with an order...not notifying the MD can result in you(not you you the collective you) being in BIG trouble if something REALLY bad goes down and the family/patient sues! If there is ONE other "reasonable and prudent nurse" who would call...your goose is cooked. It makes me angry that physicians act this way especially in small rural facilities where the are nothing but a guppy in a puddle making them appear to be a whale amongst minnows. NOTHING gets under my skin more. These MD's need to get over themselves and do their jobs!!! Pompous ass. I can be sued for NOT calling the MD. But I can't be sued because I called and made the MD angry. If I lose my job becasue of the angry doctor I'd sue and move on as this was NOT the facility to work in from the start.[/quote']
Kinda off topic but this makes me think of a recent staff meeting. Third shift being commended for NOT calling surgeons on third shift as certain ones complained we were calling too much. They also complained that we chart too much. I'm not afraid of grouchy or rude doctors but it sucks that nobody is on the side of the nurse especially dealing with surgical patients.

nurseprnRN, BSN, RN · Feb 7, 2014

Runs of V-tach can indicate that the heart muscle is irritable. That can most certainly be the result of an ongoing MI. It also happens post reperfusion , such as when the heart muscle is reperfused by cardiac catheterization and stenting.
Short runs of V-tach won't usually cause what is called a 'Demand MI'. A Demand MI is when something causes muscle injury to the heart other than occlusion of the coronary arteries. Something such as profound hypotension, where not enough blood was available for pre-load to allow the coronaries to deliver enough blood to the heart muscle.

Coronary arteries fill during diastole--- afterload, not preload, is what determines coronary artery filling pressure. They are the only arteries in the body that get less pay when they're working harder, as the contraction of the surrounding muscle briefly decreases or interrupts coronary flow.

That's why when heart rate is faster and diastolic pressure rises, it's a good thing (to a point, which is, until the afterload is so high that the myocardium can't pump against it. Balance, balance, balance...)

Esme12, ASN, BSN, RN · Feb 7, 2014

Kinda off topic but this makes me think of a recent staff meeting. Third shift being commended for NOT calling surgeons on third shift as certain ones complained we were calling too much. They also complained that we chart too much. I'm not afraid of grouchy or rude doctors but it sucks that nobody is on the side of the nurse especially dealing with surgical patients.

What does it matter to them if you chart too much....Oh I know... :facepalm:

documenting the liability of a lazy incompetent surgeon. Too bad Mr. Surgeon ....do your job. Whatever. :rolleyes:

I have to respect them to even take under consideration of their opinions. Trust me when it all goes down in court becasue of a bad out come you WILL be the bad nurse who didn't let the poor helpless MD know. He will toss you so far under the bus you will never be seen again...and the hospital will lock the gate so you can't get back in.

Been there,done that, ASN, RN · Feb 7, 2014

Most certainly V-tach is anin this situation.

Please review your cardiac physiology.

Emergent, RN · Feb 8, 2014

Coronary arteries fill during diastole--- afterload, not preload, is what determines coronary artery filling pressure. They are the only arteries in the body that get less pay when they're working harder, as the contraction of the surrounding muscle briefly decreases or interrupts coronary flow.

That's why when heart rate is faster and diastolic pressure rises, it's a good thing (to a point, which is, until the afterload is so high that the myocardium can't pump against it. Balance, balance, balance...)

Very true. But profound hypotension affects cardiac output and can compromise oxygenation to the heart.

Katniss88 · Feb 8, 2014

What I don't understand is there are lots of cases where people have survived an MI. This pt was on plavix, but had to stop taking it a few weeks before the scheduled surgery and was to continue the plavix the next day after the surgery. Then was to also take aspirin 325 mg for a while after the surgery along with plavix. The pt never got to take the plavix on POD 1 because the pt was NPO for another procedure that morning. I guess all this contributed to the issue. I keep thinking that the vt could have been a contributing factor, but an MI is caused by a blockage in the coronary arteries that supply oxygen rich blood to the heart and when those arteries are blocked the heart muscle dies from lack of oxygen.

ADeks · Feb 12, 2014

Whoa! I need to jump in here. You do realize that saying "the doctor told me" is not absolution from responsibility in COURT OF LAW. Because the doctor does not "want to be disturbed" at night-will not absolve you of responsibility. The FIRST thing that MD will do especially without a written signed order is say...."THAT is NOT what I meant!" and the facility will not have a "policy" that states this as procedure for "emergent" arrhythmia notification (believe me there won't be) and the nurse will be sold down the river! Even with an order...not notifying the MD can result in you(not you you the collective you) being in BIG trouble if something REALLY bad goes down and the family/patient sues! If there is ONE other "reasonable and prudent nurse" who would call...your goose is cooked. It makes me angry that physicians act this way especially in small rural facilities where the are nothing but a guppy in a puddle making them appear to be a whale amongst minnows. NOTHING gets under my skin more. These MD's need to get over themselves and do their jobs!!! Pompous ass. I can be sued for NOT calling the MD. But I can't be sued because I called and made the MD angry. If I lose my job becasue of the angry doctor I'd sue and move on as this was NOT the facility to work in from the start.[/quote']
We received many post cardiac caths and small runs of VTach were not uncommon. I agree that the doc should be notified, but you call once on a patient and they give you that order. Some patients would get more frequent runs and the cardiology would get a call regardless. I also checked my patient every time even waking them up to see if symptomatic.
I was a new grad. I would ask my charge nurse and she usually would tell me not to call unless the patient was symptomatic. And I agree that if that pt ended up coding this would all be on the line. I do have to say though there was this mentality to not "bother" the on call cardiologist.
I will add, I transferred to the ER. Also, that was NOT a small hospital. It was actually a large hospital and was known for it's cardiology program. That's where I think some of those cardiologists felt they were too good to be bothered.

Barbara H. · Feb 12, 2014

How sad that we have to tiptoe around some physicians...have seen it also in LTC...Why the hell do some people pick health care...just get a 8-5 job!!

UnbrokenRN09, BSN · Mar 7, 2014

Kind of off subject, but I'm wondering why this patient with significant cardiac history was allowed to have surgery without cardiac clearance first? I take care of many patients who wind up with stents when all they thought they needed was a knee surgery. I thought most surgeons won't operate on a patient they feel has risk factors for heart disease until they are cleared by a cardiologist. Usually they have to have a normal EKG and stress test. If stress or EKG is abnormal they have the angiogram. Then, if they are stented that means no surgery until they can safely be off the Plavix....usually at least a year with a drug eluting stent.

Anyway....I would think someone with significant cardiac history would need this first if it's been a while since their last angiogram just to make sure the stents are patent, and no new blockages.

Anna Flaxis, BSN, RN · Mar 7, 2014

Esme is spot on. Another point that I don't know if anyone else has made is that this patient could have been having runs of VT all the time at home, but since he was asymptomatic with them, never would have known. In other words, the runs of VT you saw in the hospital may not have been new onset at all.

It sounds like the biggest contributing factor was that he was off his Plavix for the procedure.

At any rate, yes, it would have been a good idea to at least notify the physician of your observations. I'm not sure why your charge nurse would have thought it unnecessary to do so.

Editorial Team / Admin · Mar 8, 2014

Kind of off subject, but I'm wondering why this patient with significant cardiac history was allowed to have surgery without cardiac clearance first? I take care of many patients who wind up with stents when all they thought they needed was a knee surgery. I thought most surgeons won't operate on a patient they feel has risk factors for heart disease until they are cleared by a cardiologist. Usually they have to have a normal EKG and stress test. If stress or EKG is abnormal they have the angiogram. Then, if they are stented that means no surgery until they can safely be off the Plavix....usually at least a year with a drug eluting stent.
Anyway....I would think someone with significant cardiac history would need this first if it's been a while since their last angiogram just to make sure the stents are patent, and no new blockages.

Depends on what kind of surgery is proposed.

ACC has guidelines for what sorts of preop cardiac diagnostics should be ordered/reviewed.

Tho' it is the "gold standard," coronary angiogram is not indicated as a preop diagnostic for "only" a cardiac history.

If the proposed surgery is major, and the patient is free of cardiac symptoms (i.e., experiencing no chest pain/angina) -- yet has a cardiac history -- at the very least an ETT (Stress Test) and possibly an MPI (Nuclear Medicine cardiac Imaging + stress test) would be ordered.

And things would roll from there, depending on the test results.

Carry on with the thread, please, apologies for straying from the path!

UnbrokenRN09, BSN · Mar 8, 2014

Doctors should not be allowed to write "do not call for xyz" orders. Period. That's bullying in my opinion and deters nurses from using their best judgement.

When I worked day shift I never hesitated to call. Night shift has been different...there is far more pressure from the doctors not to call at night unless it's absolutely necessary. One facility I work at, which I consider my home base, has these lovely protocols that we have permission to use in certain situations. We have an arrhythmia protocol, which calls for a stat mag and k if the pt is having frequent ectopy. So by the time I call a physician for VT runs, I've already got a mag and k and have already treated them if the levels were low. This also tells the physician we aren't having a problem with electrolytes, but something that needs to be looked into further. Now obviously if the runs were long, or caused the pt to become unstable I would just call immediately.

I think there are some situations where's it's acceptable to just pass the info along in report or or call before you leave. If a pt has KNOWN history of VT or has been doing it since they arrived and that's why they're there basically....I think it's ridiculous to keep calling the doctor every time it happens. But anytime you see something on the monitor that is a NEW change (symptomatic or not) or it causes the pt to be symptomatic you better be picking up the phone if you care about your license. Esme is so right...Doctors have no problem throwing you under the bus. You are nothing to them.