Pt was tilted with feet up - page 2

Thank you and I have a general question and i won't ever forget your answers. What does it mean when a PT is tilted with the feet up all the way and is rushed to ICU? My question is about the... Read More

  1. by   VickyRN
    jules/futureRN wrote:
    I am not a nurse yet but I had a situation happen like this to me. When I was in labor with my second child, my nurse did this to me. It was after the epideral was put in and she had asked me to let her know if I had a metal taste in my mouth or if my ears started to ring. Well as soon as she said that, I tasted metal and I before I could let her know, I had the ringing in my ears...I dont really remember much more after that except that she tilted my bed. My husband I freaked out after the situation was over. Is this what happened to me? Nobody ever told us anything.
    Used to do some OB. This can be a common occurrence after insertion of an epidural, caused by the anesthesia interference of parasympathetic and sympathetic impulses, creating an imbalance (the autonomic nervous control of the blood vessels fails). This imbalance hinders the nervous system from adequately controlling the diameter of blood vessels (often seen with spinal injuries). The blood vessels dilate and blood pools in the peripheral areas of the body away from vital organs. Once the blood vessels dilate, there is not enough blood to fill the new volume (a "relative" or distributive hypovolemia). Blood vessels then lack the pressure required to adequately circulate the blood throughout the body. Blood vessel diameter increases, the heart slows and blood pressure falls so low (from increased parasympathetic stimulation) that there is not enough oxygen being carried to the brain and unborn child. This is a type of neurogenic shock, which is quite different from hypovolemic or other types of shock, and is usually very transient--not too serious if treated promptly (which, thankfully, your nurse did). Other central nervous system controls can also be lost. Body temperature, for example, usually drops in neurogenic shock. Mom should be positioned left side-lying (should not be flat anyway), 02 via facemask 12-14 liters, and legs elevated. Fetus, of course, should be continually monitored. Can give fluid bolus (usually 1 liter LR). If BP still does not increase and mom symptomatic, used to have a standing order for ephedrine (which was at the bedside). Using this prompt treatment, this form of neurogenic shock is nearly always rapidly reversed with no harm to the mother or baby.
    Hope this helps!!!
    Last edit by VickyRN on Jun 30, '02
  2. by   jules/futureRN
    thank you, VickyRn!!!!

    It did scare us to death...very hard vbac after only 17 months!!!
    Baby needed help breathing at first and ended up in nicu...sugar levels were very high.

    We never understood what happened, but thank you for helping us understand a little more.
  3. by   Becka
    To go along with what VickyRN posted -- sometimes my GYN surg pts will have a vaso-vagal reaction. Most often just getting them into the T-berg position and putting a cold cloth on their forehead will get them stable. Sometimes not, and we end up putting them on O2 and giving atropine. If they c/o referred numbness (lips, ringing ears, etc) after getting the paracervical block with lido, I'm especially alert for the vaso sx. I don't have any hard and fast rules about when I'll put them in T-berg --- watch VS, Sx, and listen to pt. Is pulse and/or BP significantly lower than pre-op? Is she diaphoretic? or c/o feeling hot, nauseous, etc. If pre-op VS were average (vs. WNL) and she has a pulse of 50 or less with a corrosponding low BP (less than 85/55) I know I'll be getting an order for atropine. Pretty much anything up to that point is left to nursing judgment at the amb. surg center I work in.

    Becka
  4. by   CATHYW
    Mario, all of these nurses are giving you invaluable knowledge, here. I would add that the patient's LOC (level of consciousness) might have begun to alter, or perhaps their speech became slurred, or absent. This would have clued the nurse to do a rapid neuro/cardio assessment, which includes BP & pulse. The other thing might be that the person becomes pale, and their skin gets clammy. That is not a good sign-it is a sign of shock. ALWAYS get a nurse if you see anything like that.
    I'm with Micro, Mario-I think you intuit a lot more than you realize. I'm sorry, I don't remember reading-what was your previous profession?
  5. by   Zee_RN
    Cathy, you took the words right out of my mouth. Heh, I was just gonna say ASSESS THE PATIENT and there it was in the last post.

    The BP may read low (systolic less than 90, I'll say)...but if the patient is sitting there talking to me and acting normally, I'm not gonna flip him into T-berg. I'm gonna assume equipment malfunction or a transient reaction to medication or something unremarkable. But if the BP is low and the patient is symptomatic...decrease level of consciousness, c/o dizziness or lightheadedness or weakness, is diaphoretic and pale...I'm going to initiate some action. If patient is in Semi-Fowler's or higher, I'm going to lay him flat. I'm going to hang NS (assuming it's not contra-indicated) and run some in (working in ICU helps). If lying flat didn't help rather quickly, then I'm going to start working on T-berg. On a general floor--I'd be calling for a doc ASAP and doing pretty much the same measures but I'd want the doc there for transfer orders and to evaluate just why this happened.

    There's not established numbers for flipping someone into Trendelenburg. 110/60 could be a low BP for someone used to hanging in the 160s-180s. 96/50 could be normal for some (me, for instance). So it's all relative.
  6. by   -jt
    <what point at which you would take this action->

    Trendlenberg when BP is low & the pt is symptomatic. Meaning not tolerating that low BP at all & in danger of coding. The little old lady may be just fine with sBP of 80 but if shes looking a paler shade of gray, pulse too fast, is a bit sweaty, getting kind of out of it, raise her feet up, tilt her head below her heart & send the blood circulating from her legs, where its not needed right at that moment, easing the strain on her heart from trying to pump to far reaching places, & let it just flow up to her head & heart where its going to do the most good for what little there is of it circulating - until you can get more volume into her & she has more to circulate. Watch for breathing difficulties with this position. A 300 lb pt isnt going to be able to breath with his stomach sitting on his chest & ABC first - airway, breathing, THEN circulation. If he needs to be in trendlenberg, he may also need to be intubated & placed on mechanical ventilation.
  7. by   mario_ragucci
    This is a new age we are in. I am very humble and in the debt of so many people.Imagine a time when a person can see something they have questions about, ask a question, and get an answer. Then think of how long Mario will remember what a Trendelenburg is. Now I know so much about that a book or even a single live experience could not touch. Our of respect for everyone, i will thank you all individually and am so excited to learn so much. i'll refrain from asking questions for awhile and read, though this procures a different learning experience (holistic) (solid connections)
  8. by   mario_ragucci
    Originally posted by -jt
    <what point at which you would take this action->

    The little old lady may be just fine with sBP of 80 but if shes looking a paler shade of gray, .
    Yep - it was a lady and seemed strange because her color was gone. When i first walked by, and seen the people around, i thought she was dead because her color was way off. And she wasn't covered with any sheet. It was so strange, but I kept thinking what was going on inside her. I now understand so well.:kiss
  9. by   hoolahan
    Please don't stop asking questions Mario, it is a great way to learn. You can always read about something in a book, but when you see it, it really sinks in. Like learning about a tardive dyskinesia reaction to the drug compazine, until I actually saw what that was, and it was 19 years of nursing before I did, I will now never forget it! When you go into nursing, you will have to learn so much more than you can possibly experience in nursing school. You will never stop learning in this profession, if you stop learning, you stagnate and can't be effective.

    So, keep asking.
  10. by   CATHYW
    Hear, hear, Hoolihan!
  11. by   LilgirlRN
    I'm gonna agree with Micro here, always treat the patient not the monitors. In the ER we see a whole lot of vaso-vagal stuff, pts being brought in because they passed out on the toilet to patients passing out when they were stuck for an IV. For Mario's benefit this is how it works. Vagus nerve, one of the 12 cranial nerves that lie at the bottom of the brain. The nerve goes from there down through your neck into your thoracic cavity. If you stimulate this nerve, it slows your heart rate way down, sometimes as low as 30. Decreased heart rate results in decreased cardiac output and your BP plummets, which means decreased blood flow to the brain which can sometimes lead to unconsciousness. How do you stimulate the nerve? You can increase the pressure in your chest by straining as if to have a bowel movement, or by vomiting. You can let someone choke you. You can view or do something you consider disgusting, such as getting stuck with a needle. The flip side to this is if someone's heart rate is too high, sometimes we can use the above techniques to help slow them down, mostly the strain like the BM thing is used. Ice can also cause the slowing of the heart..."diver's reflex". I've never had to do much to help a person that's had a vaso-vagal episode, it's very self limiting. Basically if you are standing and have one, you will want to sit or lie down and if you don't do that quickly enough, you'll pass out and as soon as you get your head down...you have increased blood flow to the brain and the consciousness returns. Wendy
  12. by   dianah
    Most of the time the vagal episode can be self-limiting, but I've seen a pt vaso-vagal while lying on an X-ray table while the technologist set up for an arthrogram. No needle had touched the pt yet, even, but I was called because the pt c/o not feeling well: diaphoretic, pale, clammy when I ran in (no, unrelated to my appearance, folks). No IV in, no monitor on pt. Did the same as the nurse in Mario's post: first elevate legs, second start IV, third get atropine in. We have "emergency" boxes in our dept for just such times (as well as for allergy-type reactions to IV contrast). If pt had been standing or sitting, yes I'd have put him supine first thing, but he was already lying down, so on to the next tactic!
    Other posters have done tremendous job of filling in this subject to educate Mario and refresh the rest of us. You guys rock! --D
  13. by   MollyMo
    Originally posted by mario_ragucci I know I (a CNA) can ask a nurse to ck the PT because the VT's are alarming, but what does an RN do then? What are VT #'s that would cause an RN to tilt the bed and take other immediate action? It sounds chalenging to be responsible to initiate a sequence to potentially save a life. Wow.
    Seeing this left an impact on me, and I know I can't expect anyone to just explain it all to me in several sentences. I'd take any sentences i could get here. Is there a time when you would raise a persons head, and lower their feet? [IMG]http://www.websciences.org/nsf/publications/img/see-saw.gif[/I MG] [/B]
    When v-tach alarms, first the nurse must stay calm. Go into the room and check the patient. If they are awake and talking, check the telemetry leads. One is probably loose. I had a v-tach alarm and found the patient scratching her hand with a hair brush. If the patient is turning strange colors, call for help and initiate a Code Blue--the ABC's of CPR--airway,breathing and circulation until the code team arrives. If you know how and it was a witnessed arrest you can try a precordial thump. That is very cool when it works. But sometimes they get violent if they think a nurse is punching them out. We use Trendelenberg when we pull a sheath and the patient vagals. Feet up and fluid wide open until the blood pressure comes back up.

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