So, I was called in to work extra an as 'ED hold nurse' the other day, got an admitted pt for hyponatremia with hx of nasopharyngeal CA, no sx just radiation. He does have hx of autonomic nerve disorder post radiation and for the past 3 years he has wildly varying BP's. I mean when I got him, 190/130, 200/150, steadily climbing 220/160, 245/190. He states this is normal, I am starting to freak out, although he is completely asymptomatic. I am paging the admitting doctor to get orders before this guy strokes out on me. Doc phones up, orders 0.1mg clonidine PO, I ask for clarification, she says "he has autonomic nerve disorder, it's okay." So no other orders, I run and get the clonidine and give it to the pt. Pt initially refuses, says he is super-sensitive to BP meds, he takes it, at this point he is on q5 min BP. So his BP starts dropping 10 mins after admin, 170/90, 120/65, 78/59, and eventually 64/39. BTW, those BP's are 5 mins apart. I throw him in Trendelenburg, open his maintenance fluids up as I page the admitting doc again. The whole time, pt talking and watching tv, does not complain of any S/S. Doc tells me "it's okay, only phone me again if his systolic is in the 40's. DC his fluids."
I say what?
So the entire time, his HR never moves from 70-75. No complaints whatsoever. Admitting doc comes in, assesses pt and says everything is hunky-dory. She leaves, he wants to go to the bathroom, I give him a urinal. At this point I go to get my COW so I can eyeball him. Upon returning, he is out of bed and in the bathroom (did I mention our ED is like the Marriott? Private rooms with bathrooms, flat screens, I'm surprised they didn't put in marble counter tops. AND we didn't get our yearly raise, but that's another story). I run in and grab him before he syncopes on me, he is surprised that I am so surprised. Gets back in bed, BP 190/70. So now I am scratching my head, the whole time he is asymptomatic, but that varying BP is SCARY.
As he is resting, I am charting what has transpired, made sure to include "no further orders given," and the admitting doc walks back in to admit another pt. I beg of her to explain. She goes on to tell me his vagus nerve was damaged, so he has been dealing with this for the past 3 years. I ask why his HR isn't affected, or even trying to compensate, she can't give an answer. After looking at all my resources at home, using google, I can't find much.
Now I turn to the AN gurus. Has anyone encountered something like this before? Could one of YOU guys explain it, cause the admitting doc sure as heck could not. Thanks!
Last edit by thelema13 on Jan 27, '12
: Reason: spelling
Jan 27, '12
I've never seen this, just heard about it, so my guess might be completely out of left field, but just an idea.. Maybe the reason his HR isn't affected or trying to compensate is the same reason why his BP fluctuates: nerve damage. It's not out of the realm of possibility to think that, just as his BP isn't stable or adjusting like a normal individual's would, his heart rate doesn't adjust to changes like a normal individual.
Anyway, I'm probably completely wrong about all that, but I wanted to take a guess. It's curious to me as well, I'd love to hear a concrete explanation!
Jan 29, '12
I gave a detailed answer here.....as far as the heart rate not changing these patients usually have wildly varying heart rates. did he happen to have a pacemaker? as these patients often do.
Autonomic nerve disorder
Jan 29, '12
Nope, no pacer. Thanks again Esme12, I appreciate it.