[zacarias]

Hey all,


Last night was the busiest shift I've had in in several months. I've had busy shifts but this one was downright crazy!!! I didn't have a break ever and was constantly on the move. The night did go by fast...but then I was so worried I'd never get done.
I had two admits and a transfer, but let me discuss just one admit. He comes in with N/V and rapid afib with wide complex. They hook him up to NGT to LIS in ER and his belly starts feeling better. He comes up and I see that he's to go on a diltiazem gtt. It takes forever (well like a 1/2 hour) for pharmacy to send up the bag. I finally find a pump (the hospital was like out of pumps) and give him 10mg dilt (bolus). I start the gtt at 5gtt and his BP holds great, get it up to 10. I wait a while and his HR is like 150 with occasional bursts to 180. He's asymptomatic. After like 45 min to an hour I turn it up to 15. His blood pressure holds but I want to wait to see if this works. Sometimes his rate would go down to 140 but then it hang at 150-160. Almost an hour later, I am not seeing any improvement so I give him IV Dig 250 mcgs as ordered by doc originally if Dilt didn't get HR <130. By this time my shift is over almost. Before I left he had slightly come down to 130s to 140s but then he would go to 150s. I explained all this to the day shift round and of course the docs would round but what is the next step? Amio? He's had afib for years.
Should I have gone through the dilt titration faster? I didn't want to bottom out his BP and he was asymptomatic. Does dilt IV work pretty fast?
Thanks for reading. I'm gonna try to get some sleep LOL.

[Dinith88]

That sucks you were so busy!. And yes, it seems you did everything right and had your stuff in order. Amio may have been the next step i suppose, or perhaps some beta-blockers. The biggest thing someone can come away with from this post is that you never panicked(sp?). Rates like that probably had all the nurses on your floor nervous...walking by the monitor and making comments *("wow...whatcha doin for that rate/...cardizaem aint workin...that guy needs to be in the unit"...etc. ad nauseum). If he wasn't symptomatic with that rate then there was really no reason to sweat it. And like you said he was a chronic a-fibber. Perhaps he had an undelying issue (you said his stomach needed pumped) driving the rates. Once that issue gets resolved his rates may come down all on their own...

[telehead]

Based on the info provided, it seems to me you did everything right... possibly could have taken the cardizem up a little quicker or higher (our tele unit limit for cardizem is 20mg/hr) but that doesn't sound like it would have done much.

Agree with Dinith regarding a beta blocker- sometimes 5mg iv lopressor q5 minutes x3 works well (and often doesn't even require the third dose). Since the doc ordered dig, I'm surprised he/she didn't order a follow-up dose of that as well... Amio would have been a good choice as well...

How old was the pt? Underlying cardiac issues? Renal status? Pulmonary status? Current EKG/enzymes?

You can usually fix BP issues with a fluid bolus (or 3 )...

[zacarias]

Thanks you guys for your reassurance and suggestions. It turned out that they tried dig again, and then lopressor x 3. The guy apparently was refractory to diltiazem!

[Indy]

Refractory to cardizem? Explain that one please, I haven't heard it before. Do you just mean that it has the opposite effect, or no effect?

I've had two patients who didn't convert with cardizem. One didn't convert, didn't slow down much either, with cardizem, digoxin IV, Lopressor IV, etc. Then he had a massive GI bleed and died the next day. The other was chronic in the 100's to 130's and had been intolerant of amiodarone so that wasn't a problem. She would slow down to 90's on cardizem drip but get up in the 130's and be symptomatic with her BP on PO cardizem. And it didn't help that she knew all of this and would worry about it nonstop.

But I hadn't heard anyone say these two were "refractory" to it. Interesting.

[TachyBrady]

Hi Zac,

It sounds like you acted appropriately. In my experience, cardizem works fairly quickly and is effective in most cases. However, we just had a pt the other night from ER with an amiodorone drip for UCAF. When I asked why, they said amio is what worked for this pt in the past. Sure enough, the pt had converted to SR within an hour.

My question for you is.... why was the cardizem not initiated on your pt in the ER? I would think that a HR of 150-180 would take priority over complaints of nausea. I would consider this pt unstable and don't think I would have accepted him. They have the drugs and doctor readily available in ER. In my hospital, ER is responsible for initial treatment and this pt would require 1:1 care with titration which is not doable on a busy telemetry unit. Just curious.

[WV_heart_RN]

Berna, I work tele step-down. We consistently get the patients running AFib RVR and start the dilt. gtts. I have gotten them from ER and as transfers.

If they are asymptomatic they do not go to the unit. So long as the vitals are holding out we get them first. We just had one two days ago who was systolic in the 70s running 170 HR. We were running fluid boluses and titrating gtt at the same time. Was NOT a pretty sight at all.

Anyway, it is standard for our floor to start the drips. BUT I agree with you. It would be nice if ER would start them but ......

[Angie O'Plasty, RN]

So just out of curiosity, how were his Lytes?

[neneRN]

I work in ER and am surprised that a pt would get sent to you with HR that high without the gtt getting started in the ER...I guess all hospitals are different.
Just curious as to why he only got a 10mg bolus? We give .25mg/kg bolus, wait 15 min and give another .35mg/kg bolus before starting the gtt; in my experience the two boluses are what generally bring the HR down and then the gtt maintains it. I know everybody responds differently and the larger boluses may not have made a difference either...but that's how our protocol is written and usually works very well.

[TachyBrady]

One would think that if they expected you to initiate the drips, they could at least allow you to stock the drug in your department.