[newtelenurse]

Hi,
Recently took care of a 90 yr. old lady who came in with syncopal episode. No medical history to speak of. When she got to ER she had 3 stools. Arrived on the floor and had loose maroon colored stool for me. Asked the pt. She said she had cramps all day at home. No BM's. When I asked her about the ones in ER she said she didn't pay attention to the color. Failed to get the BM news in report---came at shift change and I got report about 3rd hand I think. ANYWAY, vitals all fine. BP actually 150's over 70's I think. One more stool of the same. Then one more that was actually very small, minimal red blood this time. All this from 7-12.
Then at 5:45. Took her to the bathroom. Another nurse went in to get her out. Heard her calling for me. Pt. slumped over. Starring. Drooling. Sounds like agonal breathing. No response to name or sternal rub. She does have a pulse. SR with PVC's on the monitor. Took about 5 minutes to lift her off the toilet and man(woman)handle her to the bed. No response throughout. Called code.

OK- BP 168/64. Still in SR. Agonal breathing. Put on 02, started fluids and she came to in about 5-10 minutes. Slowly, yawning. Resource nurse said she vagaled even though her HR was in the 70's. Baseline in the 90's...is that possible?? I just don't get that. As far as the PVC's go, I went back thru and they were frequent but not a run. What do you think?? Did she simply vagal out by a drop in HR 90's - 70's?? Would appreciate any enlightenment here.

ALSO, feel like an idiot calling a code if it was a vagal response. UGH!! Where did I put my nursing manual?!?!?!?!?! LOL
Thanks!!

[TigerGalLE]

Don't feel like an idiot for calling a code. Maybe more a Rapid Response type situation... But if my patient did that you'd better believe I'd be calling someone. A sudden change in status is serious and needs to be handled seriously. So you definitely did the right thing. As far as your question about the vagal response... i dunno

[TiredMD]

Originally Posted by newtelenurse

Called code.

OK- BP 168/64. Still in SR. Agonal breathing. Put on 02, started fluids and she came to in about 5-10 minutes. Slowly, yawning. Resource nurse said she vagaled even though her HR was in the 70's. Baseline in the 90's...is that possible?? I just don't get that. As far as the PVC's go, I went back thru and they were frequent but not a run. What do you think?? Did she simply vagal out by a drop in HR 90's - 70's?? Would appreciate any enlightenment here.

Good call!

Maybe vasovagal, and certainly I'm not an expert in geriatrics, but there are a number of worrisome features to this story, including the history of syncope and prolonged recovery phase. This could have been anything from a seizure to a heart attack to a stroke. In my relative inexperience, any acute change in mental status warrants a code.

I hope no one gave you any guff about this, because in my mind you did 100% the right thing.

[Dierdre]

With maroon coloured stools, I would have notified the physician of the possibility of a GI Bleed instantly if not sooner, gotten an order for a hemacult, and then let him know the result of the test. What you may have been dealing with was not a vasovagal reaction, but a vasodepressor reaction, which can be brought on by rapid fluid (including blood) loss.

Yeah, it was an emergent situation, and you did the right thing calling the team.

[NancyNurse08]

Doesn't sound like any vasovagal I've ever witnessed. Usually you see a significant drop in HR & BP.

[suanna]

Vasovagal hypotension and or bradycardia can be very short lived - she may have recovered her BP and HR before you got to the assessment. LOC indicated a circulatory loss of some sort without other changes in labs or seizure history. I think Vasovagal is the most likely option- especialy since she was on the vasovagal throne at the time. You can stroke from the hypotension of a VV episode- not to mention mesenteric infarct, pulmonary colapse, MI, just oodles of bad things. A code was warrented if for nothing else a sudden LOC with change in resp status.

[decartes]

Sounds like Elvis.

[NancyNurse08]

There's no way to know. Not enough info.

[newtelenurse]

Originally Posted by Dierdre

With maroon coloured stools, I would have notified the physician of the possibility of a GI Bleed instantly if not sooner, gotten an order for a hemacult, and then let him know the result of the test. What you may have been dealing with was not a vasovagal reaction, but a vasodepressor reaction, which can be brought on by rapid fluid (including blood) loss.

Yeah, it was an emergent situation, and you did the right thing calling the team.

I did get the occult stool sample after the first. It was positive. Did call the Doc---sorry I left all that out of the story. I am just more focused on the possibility this was vasal response. Resource nurse seemed so convinced....

[newtelenurse]

Originally Posted by NancyNurse08

Doesn't sound like any vasovagal I've ever witnessed. Usually you see a significant drop in HR & BP.

That's exactly what I thought....