Experience off of orientation

[DustinRN]

I had a patient on Friday, Saturday, and Sunday night. This patient has had an aneuresym clipped from an infratentorial bleed. This patient is severely confused and wants to get out of bed. The pt pulled it's IV on Saturday night and pulled out his Art line on Sunday night. Anyways, Saturday night I maxed him out on Morphine which was ordered 2-10mg q 2hrs. Well, I had maxed him out on MSO4 with two doses of 5 and 5. Making sure to keep an eye on his blood pressure because the MD wants him between 120 and 160 systolic BP to prevent vasospasm. He is getting MIV at 250 cc/hr to keep his BP a little elevated. Needless to say he didn't respond to the MSO4. So, I gave him 5mg of Haldol, which was also ordered. About 5-10 minutes later he goes straight to an atrial fib/flutter wave form at 210 bpm. So, I give him Labetolol which is the only thing that I have ordered that will bring his HR down at all. The Trandate was being used to control the BP not to deal with the heart. I haven't had the time to look it up, but I believe Trandate has a greater affinity for B2 receptors than B1 anyways. Well I have him the Trandate and he gets down to an atrial fib/flutter switching back and fourth between the two at a rate of around 160bpm. I page the Neuro Surg and he says give him 20mg of Cardizem and call me back to let me know what he's doing. Well I give the Cardizem and he drops his rate to about 145bpm, still going back between the two rhythms. Well the Neuro Surgeon says start him on a Cardizem gtt at 5mg/hr and titrate to keep the HR less than 120. Well that was all fine and well, but the point is the Cardizem gtt didn't keep him below 120bpm, until he decided to calm down and rest from all the exhaustion of fighting us. So now he's maxed out on Cardizem at 20mg/hr and his HR dependent on how agitated he is. So now I'm not touching him with Haldol because I'm afraid that is what put him in that rhythm to begin with. Upon the stat EKG prolonged QT interval was one of findings on the graph. Does anyone else have experiences like this with Haldol? I mean I was about a nervous wreck when I left the hospital that morning. I know before he came in he was having some ectopy isssues with PVC's and PAC's, but I'm just convinced that I did it with the Haldol. I'm afraid to use it now. Anyways, I was just like some feedback on what other neuro nurses think.

It's been a while since I've posted over here.

[imnmk_rn]

A couple of thoughts for you....

First, was he agitated as an ongoing sort of thing? Or was that how he "expressed" his vasospasm? Not that that would change how you would treat his agitation by a whole lot, except that it would prove that you want to keep his BP up.

Second, was he diuresing well enough? Though many neuro pts have issues with cerebral salt wasting and diurese all the fluid you give them no matter what you do, you do have to be careful that you are not fluid overloading them. What I am getting at is that fluid overload could have pushed him into A fib. Basically, what we always have to keep in mind is that what we are doing to treat our neuro pts, esp if they're having issues with vasospasm, puts a stress on their cardiovascular systems and it can be hard to find a happy medium. Our neuro interventional radiologists and neurosurgeons like our pts' BP up above 160 after their aneurysm is secured (coiled or clipped), so we often have them on plenty of IV fluid as well as pressors. But it definitely stresses the heart.

About the Haldol, you are right that it can cause prolonged QT intervals. I honestly have only seen in once (though I am by far not the most experienced in this area), and it was really over a longer period of time where the pt had been getting Haldol on a regular basis. To be honest, my guess is that the stress on the heart was contributing to EKG changes more than the Haldol did, but you are right to question giving it.

I don't know if any of that helps - I don't have all the answers but maybe that helps process it.