Interesting tidbit on age factor in tx MIs

[Tink RN]

Last week in the ER I received a 44 year old male patient via EMS who presented with c/o sudden onset chest pain, SOB and nausea that started about 45 min PTA. No prior history,VSS. EKG showed tracings indicating an inferior MI. We did the usual cardiac work up including starting heparin and nitro gtts - then the ER Doc called the Cardiologist.

Well ... as usual the Cardiologist was busy with a procedure so the ER Doc had to make the decision whether or not to administer IV TNKase ("clot buster medicine" for those of you not familiar with it). Well ... he ordered it and I gave it. Welcome to ER autonomy. ER Doc leaves to tx the other 70 people in the ER.

Pushing TNKase always makes me nervous because not only is there a risk of internal bleeding / hemorrhaging but after you push it, you start seeing really funky rhythyms on the monitor as the pt starts to reperfuse. I've given this med several times, but I wasn't AS nervous this time because I was thinking, "hmm ... he's young ... no prior cardiac history ... this should be a breeze". WRONG!!!

Several minutes later he started having occassional PVCs ... his blood pressure starts dropping and his heart rate dwindles from 70s to 40s ... 30s ... I stopped the nitro gtt, checked manual B/P which was 70/30 so I "trendelenburged" him and started NS bolus. I called for the ER Doc but he didn't answer so I put stat pads on the pt. The pt was cold and clammy, white as chalk but he was still with it enough to answer simple "yes or no" questions. Then ... solid run of V-Tach on the monitor ... HR dwindles to 23 ... then asystole. Seemed like minutes, but in reality only seconds ... he had a perfect sinus rhythym - B/P 100/60, HR 72, he was pink again. He reperfused, but he scared the he*# out of me doing it!!!

Then the ER Doc rolls by and says, "Ah yeah ... were doing good. He might be more comfortable if you set him up a little." I wanted to kick him. When the Cardiologist came to the ER I told him what happened and asked him why. The answer is simple, but I didn't know this so I'll share: "A younger person with no previous heart problems is more difficult to treat with an MI. The reason being is that most older patients or patients with prior cardiac history have developed the clot slowly over a period of time and have adjusted to and developed alternate means of perfusion, however as in this case, the clot apparently developed and lodged quickly."

I don't think any competent nurse would be totally nonchalant about administering this type of med, but keep in mind with acute MIs, younger is not better!

[Noney]

Good point Tink.

Noney

[sharann, BSN, RN]

It's the same for patients in recovery from surgery. It's always the young strapping bucks that crash on us after "simple surgery". There is no "routine" surgery. Surgery is surgery. At least you learned something new Tink. You will never assume that youth=stable MI (ha ha)

[gwenith, BSN, RN]

Thank-you for sharing Tink. Although intellectually we may know about collateral circulation development in long standing disease actually putting in a patient context always assists with remembering it for next time!!!

Good scenario.

I loved the bit about the Doc coming in a saying "He would be better if you sat him up" Don't you just LOVE it when that happens???

[Tweety, BSN, RN]

Thanks for sharing that experience. Every day is a lesson learned isn't it?