[Indy]

Okay, I couldn't figure this patient out. He wasn't my patient and I hadn't even read his H&P. Background: week from hell, third night on understaffed tele unit, me and another nurse who worked all 3 nights together, same unit. I'm in charge and it's bad if I haven't read the documents on any patients other than mine.

Ok so this guy came in first night with ... I wanna say he was a chest painer with ETOH issues, tranxene protocol and watch him. Second night he's had a cardiology consult and echo showed a floppy leaflet in his mitral valve. Still on tranxene protocol. Skinny little dude, almost cachectic, good affect, reminds me of a parkinson's patient because I always find him in the same arms-drawn-up positon.

Third night he's prepped for cardiac cath and consult CT surgery on whether he's a candidate to fix that valve. At 0430 heart rate shoots up to 170's and goes down to 120's. He was getting up to weigh. No problem. But over the next half hour it just won't come back down, goes 120's to 160's and I can't tell if it's afib or what the heck it is. Until 0520-ish his blood pressure holds steady 90's systolic. Then it drops to 70's systolic and that took about ten to fifteen minutes. I'm hearing the same thing manually and it's kinda thready. He's alert, oriented, and telling us that the high heart rate is because he likes his nurses.

We know from house supervisor that his cardiologist on call is right in the middle of something dire, and the hospitalist says to leave him alone, and that "digoxin won't work." Ok. CT surgery sends their PA to see him, and I tell her what's going on. She orders a cardizem drip. We are sure this is what the cardiologist would have spat out, so I dicker with her over the bolus and the rate and she comes out with 10 mg bolus, start rate at 5 and use protocol.

While all this is going on, I've taken 4 people to the bathroom, taken a blood sugar, and hung an antibiotic on my patients. The patient's nurse hasn't had time to do squat; she just started a cardizem drip not an hour ago on one of her other a-fibbers. So she's behind. We have a brief conversation about his blood pressure and I say "hmm. Maybe it'll drop his rate and that'll help the BP go up, and maybe we can get fluids in him fast enough if it bottoms him out, before he dies." Anyhow it doesn't seem like a good idea to let him go any longer with that ridiculous heart rate.

So I gave the bolus, slowly, start the drip, and turn it off about two minutes later d/t a blood pressure of 60/50. I could not believe my ears! The heart rate dropped to 80's but stayed irregular, the patient was still arousable. I really thought dropping the rate would help the cardiac output and raise the blood pressure; I'm sure the PA thought the same thing or she wouldn't have ordered cardizem in the first place. Oh. Almost forgot. He did get his AM Lopressor PO early prior to calling any docs. It didn't do squat.

Anyhow, he wound up getting 500 ml NS, blood pressure stabilized, still flirting with his nurses, 0700 comes around and the cardiologist who's gonna do the cath is informed and says it's all okay, he'll do the procedure. Nobody, that I know of, is questioning that what was done, was done, but simply how did we manage with two nurses. The patients were all ... interesting, needy, mean or just plain sick. AM shift thought it was so bad they called in another nurse after getting an idea of what was going on.

So I can't figure out what else, what other drug, should I have asked for? Do you ever "just leave it alone" when it's SVT on a CHF'er (kinda early CHF, but he diuresed well), with a floppy mitral valve? I wondered about low dose dopamine drip combined with IV verapamil... or digoxin... I'm trying to not call work in the middle of the night to find out what happened to this guy. Any ideas?

[Dinith88]

Originally Posted by Indy

Okay, I couldn't figure this patient out. He wasn't my patient and I hadn't even read his H&P. Background: week from hell, third night on understaffed tele unit, me and another nurse who worked all 3 nights together, same unit. I'm in charge and it's bad if I haven't read the documents on any patients other than mine.

Ok so this guy came in first night with ... I wanna say he was a chest painer with ETOH issues, tranxene protocol and watch him. Second night he's had a cardiology consult and echo showed a floppy leaflet in his mitral valve. Still on tranxene protocol. Skinny little dude, almost cachectic, good affect, reminds me of a parkinson's patient because I always find him in the same arms-drawn-up positon.

Third night he's prepped for cardiac cath and consult CT surgery on whether he's a candidate to fix that valve. At 0430 heart rate shoots up to 170's and goes down to 120's. He was getting up to weigh. No problem. But over the next half hour it just won't come back down, goes 120's to 160's and I can't tell if it's afib or what the heck it is. Until 0520-ish his blood pressure holds steady 90's systolic. Then it drops to 70's systolic and that took about ten to fifteen minutes. I'm hearing the same thing manually and it's kinda thready. He's alert, oriented, and telling us that the high heart rate is because he likes his nurses.

We know from house supervisor that his cardiologist on call is right in the middle of something dire, and the hospitalist says to leave him alone, and that "digoxin won't work." Ok. CT surgery sends their PA to see him, and I tell her what's going on. She orders a cardizem drip. We are sure this is what the cardiologist would have spat out, so I dicker with her over the bolus and the rate and she comes out with 10 mg bolus, start rate at 5 and use protocol.

While all this is going on, I've taken 4 people to the bathroom, taken a blood sugar, and hung an antibiotic on my patients. The patient's nurse hasn't had time to do squat; she just started a cardizem drip not an hour ago on one of her other a-fibbers. So she's behind. We have a brief conversation about his blood pressure and I say "hmm. Maybe it'll drop his rate and that'll help the BP go up, and maybe we can get fluids in him fast enough if it bottoms him out, before he dies." Anyhow it doesn't seem like a good idea to let him go any longer with that ridiculous heart rate.

So I gave the bolus, slowly, start the drip, and turn it off about two minutes later d/t a blood pressure of 60/50. I could not believe my ears! The heart rate dropped to 80's but stayed irregular, the patient was still arousable. I really thought dropping the rate would help the cardiac output and raise the blood pressure; I'm sure the PA thought the same thing or she wouldn't have ordered cardizem in the first place. Oh. Almost forgot. He did get his AM Lopressor PO early prior to calling any docs. It didn't do squat.

Anyhow, he wound up getting 500 ml NS, blood pressure stabilized, still flirting with his nurses, 0700 comes around and the cardiologist who's gonna do the cath is informed and says it's all okay, he'll do the procedure. Nobody, that I know of, is questioning that what was done, was done, but simply how did we manage with two nurses. The patients were all ... interesting, needy, mean or just plain sick. AM shift thought it was so bad they called in another nurse after getting an idea of what was going on.

So I can't figure out what else, what other drug, should I have asked for? Do you ever "just leave it alone" when it's SVT on a CHF'er (kinda early CHF, but he diuresed well), with a floppy mitral valve? I wondered about low dose dopamine drip combined with IV verapamil... or digoxin... I'm trying to not call work in the middle of the night to find out what happened to this guy. Any ideas?

You're correct that lowering the rate would've improved his cardiac output, unfortunately some people are sensitive to cardizem and their pressure takes a dive. Dig will work (and sometimes convert the rhythm) but it takes awhile...so isnt very useful in emergent situations (i think thats what the doc meant by 'it wont help'). Verapamil is also a calcium channel blocker so the guy'd probably have a similar reaction to it...and starting a pressor (dopa) could have the opposite effect and exacerbate his tachycardia.

IN my opinion, as long as the guy was asymptomatic, lanoxin would be a good choice...or perhaps trying the cardizem without a bolus...and titrating slowly. Cordarone is a good(great) drug but also can cause hypotension...though usually not as profound as cardizem (and mostly reserved as a last line for atrial rhythms d/t it's numerous potential side-effects). If the guy started to go out, or was otherwise unstable, he'd have to get shocked. As long as the guy has a decent LV (and his MR isnt too profound), he could probably go awhile with a heart rate in the 140's-150's before it'd cause a crash. The hospitalist who told you 'dig wont work' should go back to school and re-read his cardiology stuff.

[Indy]

Thanks for the reply. I made myself relax some and enjoy the weekend; maybe I'll find out in the next few days what happened to this guy. His mental status and brain perfusion was something I was questioning at the time all this was going on. He wasn't quite somnolent, but unless you poked/moved him enough, and talked to him enough, he'd just lay there. Then when I've decided he's approaching unresponsive, he opens his eyes and says something about how cute the nurses are. Good grief.

[Whisper]

I had a similar patient, bombing along at around 160-170, pressure fine for most of the night then suddenly dropped, but the patient was fine and alert and talking with bp 65-70 mmhg systolic!

He had both po loading doses of digoxin, with no effect, was not to have ammiodarone as he had previously flipped from af to vt with that.

We did, nothing, well we watched him like a hawk, trickled more n/saline in with his IVAB (the guy was an SBE that had MV/reg) and were told not to give any more rate control unless he became symptomatic with the low bp.

His rate dropped on its own and BP started improving, but this happened on a busy nights shift and we felt like we were doing nothing, trust me we had everything documented, just in case

[Indy]

It's so frustrating to watch something like that, without doing something about it. I always hesitate to come post something like that for review... but some things, yano. It helps to know others have had that experience so I can relax and let it go.

The patient is fine. He's having his MVR and had a day or so of an amiodarone drip, no further excitement with the heart rate.

[zacarias]

I think you did great with this guy although I fear that another patient might have severely crashed in this same situation. His pressure was already not that great and to hope that "lowering his HR would increase CO" is good in theory, but what if this guy kept plummeting until death. I don't know if I'd take that chance.

[WOLFE]

sometimes we do cardizem drip and add the dig iv in doses ..but dig doesn't always work..also with bp issues, we have been known to hang nss to increase the bp and hang the cardizem to decrease the hr at the same time...and i have also seen lopressor iv given, even if a person has received their dose for the day.

[Indy]

Hmm. I think that's a good idea, to start the NS at the same time as the cardizem. In this patient's case, his fluid bolus got started approximately 3-5 minutes after the cardizem bolus. I really would've done better taking a bag of NS in the room in the first place, particularly since I was thinking of how risky it was to begin with.

Most of the situations I've seen, haven't come around again. I'm only a year and a half into this nursing thing. But I've got little bits of hindsight set aside for when they do come around again!

[Marnaby]

Sorry to hear about your horrible night w/ that patient. They may also have been able to try doing an Amiodarone bolus w/ a drip. Still can drop the blood pressure, but it's another option. Then they can load the patient on PO amio.

Did they think about starting him on PO dilt? Or did they just try the drip?

[Indy]

Well the patient was due in cath lab two hours after my shift. So the doc who was to do the cath, was notified and he basically said "ok I'll see him in a little while." He got an amiodarone drip after his cath and a valve replacement after his teeth were pulled and infectious disease doc cleared him for that. He did fine, other than scaring the bejeesus out of me.