[MedicRN151]

I had an elderly patient a few nights ago that was in sustained SVT with a heart rate in the 160's. It wouldn't respond to two diltiazem boluses or a metoprolol bolus. (I had Glucagon and Calcium at bedside...ya never know!)
Anyway, the admitting doc ordered a cardizem titration drip. I spent a little time upping the rate until I hit the max of 15 mg/hr. That d*** heart rate still wouldn't go down. I got new orders for a Amiodarone drip, but I only had one line. She was an extremely hard stick and the whole ER was taking turns. As she was starting to deteriorate, I called the pharmacy to find out if I could piggyback it while looking for another line and was told I couldn't because the was not enough information on the compatiblities. While this patient was CTD, a new hire RN orientee said that she used to do it in the ICU she worked at all the time, and that it should be okay.
Would you guys have taken the chance on piggybacking those meds because of the pt's condition?
(A little more information: BNP 2200, Elevated cardiac enzymes, WBC 24, lungs filling, and sats out at 92% on NRB. Doc wouldn't order for a central line to be placed by the ED physician.)
I have been tossing this one around in my head for the past couple of days trying to figure out what I could have done to improve on the patient's care.

[cniro7]

Hi:

I haven't been in the ED long and am a new grad, but we recently had an elderly pt that was in SVT and our docs had us follow the ACLS algorithm. We gave 300 IVP adenosine and then 150 and she converted to NSR. They were also talking about possibly cardioverting. Was your pt in afib or something else? Usually with afib, metropolol will bring them back to NSR. The other thing that is kind of strange to me is that they wouldn't order a central line...

Interested in hearing from those with experience......

Carla

[GilaRN]

Hard to say without actually caring for the patient. It sounds like he was in failure. CCB + B blockers can be a very bad combination with failure patients. What were the patients pressures?

If pharmacy says no and something bad happens, you may be looking for another line of work. It sounds like you made a sound decision regarding the amiodarone. One has to wonder if this was in fact an actual rate problem. With a BNP of 2200 and elevated enzymes, failure seems to be one of the primary problems.

[MedicRN151]

In one of the very brief moments her heart rate dropped below 140, I could see fib/flutter. EMS gave adenosine in the field with limited effect. And I also wonder why a central line wasn't started. If I had this patient on my truck when I was a paramedic, I would have started an EJ or a femoral line in a heartbeat....or in her case, in 30 heartbeats.

[MedicRN151]

Gila, I agree, I think it was a pump problem as well. I think one of the things that bothered me the most was that if this patient didn't receive the amio, she wasn't going to do too well. I didn't want to have a nagging question in my mind about whether taking that risk might have saved the patient's life or not.

[mmutk]

Did they adenosine her at 18mg? was she swollen up? Maybe lots of lasix unless she was already hypotensive?

You said saved her life, did she die in the ER?

[ICU_floater]

Originally Posted by GilaRN

Hard to say without actually caring for the patient. It sounds like he was in failure. CCB + B blockers can be a very bad combination with failure patients. What were the patients pressures?

If pharmacy says no and something bad happens, you may be looking for another line of work. It sounds like you made a sound decision regarding the amiodarone. One has to wonder if this was in fact an actual rate problem. With a BNP of 2200 and elevated enzymes, failure seems to be one of the primary problems.

Well, you mix them and the line clots off, now you're really in a mess. Personally I don' know your protocols, but I would have called the MD to order the line and explain current therapy wasn't working,pt. deteriorating and the two meds can't be run together (the doc's don't know compatability). and at that point I would have firmly requested the central line. The INR may have been out of wack, but as mentioned, the ED doc could have dropped an EJ.

Many times afib is exacerbated by conditions like sepsis, chf, dehydration... treating the HR is not the priority as alleivating the condition that caused it.

I cringe at ER docs and nurses wanting to drop a HR of 140 in a septic patient. Can you say "cardiac output?? "

Medic. Adenosine is NOT used to treat, it's used to diagnose the underlying rhythm in a tachycardia... it slows down the rate to see whats under there... if you're really lucky the rhythm breaks but it's rare.

[MedicRN151]

mmtuk, sorry I was posting in the hypothetical mindset that she would have coded. She didn't, at least not before shift change. But I always think about the "What might have beens". And no, she didn't have any peripheral edema, which lead me to think she was going into left sided heart failure.

[Sweetooth EMT-P, RN]

Did someone say syncronyzed cardioversion? If this patietn was filling up secondary to her HR and not vise versa, this should have been concidered. A little sedation and electricity can go a long way. ALTHOUGH I THINK IN THIS PATIENT"S CASE IT WAS HER/HIS RESPIRATORY STATUS CAUSING THE INCREASED HR AND NOT THE OTHER WAY AROUND.

Also I am wondering if the HR may have been caused by this patients heart failure (and possible fever related to elevated WBC) rather than the heart failure being caused by the HR...And that woudl explain why the rate would be refractory to medications. In that case one would need to treat the respiratory problem first. Sounds like this patient had CHF with pneumonia. This patient may have been a chronic a-fibber who only had an uncontrolled ventricular rate becuase hypoxemia and possible fever.

From my experience when a patient is refractory to meds it is because their heart rate is compensating for something else. Also it is a bad idea to give someone in heart failure cardizem especially, and beta blockers should be withheld during the acute phases (ie. when their lungs are full), amiodarone can also further decrease cardiac output..

Swtooth

[TachyBrady]

You could have held the cardizem for a trial of the amiodorone since the cardizem wasn't working anyway. In an emergent situation like that, what have you got to lose? I agree though that once the cause is corrected, the HR hopefully will normalize on its own.