Another question...

Another question for all you experienced CC ICU nurses:

Had a pt transferred from outlying hospital the other night. Female, fiftyish, no notable health history. Two weeks prior had presented to doctor's office, complaining of GERD-type problems. Doc did not test for cardiac or any other blood work, simply put her on gastric pump inhibitor medicine. Pt started feeling VERY weak, SOB night before--hubby, who is diabetic, checks her blood sugar--it's in 400 range!!! Take her to ED, is diagnosed with acute anterior MI, TPA'd her and sent her to our unit. All the while, NO CHEST PAIN, maybe a little chest pressure, extreme weakness, SHORTNESS OF BREATH, some nausea-- the only presenting symptoms.

First set of cardiac enzymes, very high (don't remember exactly, think MB's 158.... troponin 88). Lactic acid level is 10. ABG with pH 7.2, pC02 around 19, bicarb around 9. RR labored, still blowing off C02. Put on 02 @ 4lpnc. Having recurrent nausea/emesis, NO CHEST PAIN. Given Phenergan IV for nausea. Crackles lower bases posteriorly. No urinary output since noon that day. Given lasix 20mg IV and also bolus NS 250cc/hr and 50cc/hr maintenance. FC inserted with about 150cc cloudy amber urine. Residents/fellow/attending aware--this is around 10 o'clock at night. Around 4 or 5 in morning, troponin increased to 133!!! New lactic acid level around 4. Towards change of shift, pt becoming increasingly critical with that bad cardiac look, "I can't catch my breath," really working at breathing, looking pale, nauseous. Crackles still lower bases posteriorly, all other lung fields clear. 1000cc urine out during the night. Given 60mg lasix IV. They took her down to cath lab emergently around 7:30, only for her to return on a balloon pump and at some point she was intubated. Next day, I heard she went for CT surgery. Haven't heard anything more.

Have a couple of questions regarding this case:

1) Diabetic lactoacidosis--she was put on an insulin drip and blood sugars started dropping accordingly, finally down to 125 when drip stopped in AM. The doctors stated there are 3 different types of diabetic acidosis. Also, have heard high lactic acid levels are OMINOUS sign for cardiac patients--signals severe left ventricular dysfunction (her EF at bedside echo that night was only 10-15%). Beginnings of cardiogenic shock. Not enough blood circulating to body cells from loss of heart pumping action. Forcing body cells to go into anaerobic metabolism, producing high lactic acid levels as a byproduct. Anybody with any better understanding (the "big picture") of lactoacidosis out there??? Appreciate your input.

2) Should she have been taken to cath lab emergently much earlier--say 11PM that night when her first set came back so positive. It was obvious then, she was actively infarcting, even though she did not present with the classic MALE "clenched fist over chest" symptoms. At least, should they have not sent her down @ 4AM with second set trending upward so ominously? TIME IS MUSCLE. I know they HATE calling the cath lab in emergently--only do it as a last resort--I have noticed mainly with MALE patients. Will even let patients (such as mine) sit on an active infarction during the night, only to EMERGENTLY take to cath lab first thing in AM. My nurse manager told me the reason the docs did not do so was because she was not having chest pain. Doesn't make much sense. Anybody with any ideas on this out there??? I am pretty inexperienced, having only worked in the unit 5 months.

WHAT DO YOU ALL THINK????

[live4today, RN]

I'm sure you already know this, but being that women often present with totally different s/s than male patients when they are having a heart attack, those docs should have known better, IMHO. Many women will present with GERD, nausea, emesis, a feeling of malaise, maybe even some right flank pain, etc. Sounds to me like the doc that patient saw two weeks prior is the one who initally missed the s/s of the beginnings of that patient having cardiac problems, but that in no way excuses the docs who treated her once she was admitted with further s/s of the same. Many male docs today don't know to check a woman for possible MI's unless they present with the same s/s of a male having a MI. This is an area of health and wellness that needs a lot of teaching, especially with male docs.

Use to be only men having heart attacks, and those men always presented with the same "classic signs" of an MI. Now that women have joined the hard working class of our male counterparts, stress is greatly increased in their lives, and therefore, causing the rise of cardiac problems in females.

Just like docs today treat women for depression too quickly rather than to check their hormone levels to see if they are actually going through perimenopause or menopause itself, instead. So much needs to be done in the area of female health care today because times have changed, making the female just as susceptible to illnesses previously known to crop up in the male population in years past.

Perhaps, healingtouch, you can present a seminar to the docs and staff on your unit in regards to the changing health problems in women, and the different s/s women will often present with that their male counterparts may not. GERDS is often one of those symptoms, too.

_________________________________________

"Change starts when someone sees the next step."-- William Drayton -- and may I add -- ...sees the next step and ACTS on it bringing about change where change needs to be recognized.

[mattcastens]

Yet again, an example of sexism in cardiology! To be fair, though, I have seen signs that it is improving.

Another point, HT, is that with blood sugars this high, I am under the impression that this woman is a diabetic. Diabetics, either male or female, frequently don't have chest pain because of neuropathy. Should she have been taken to cath lab immediately? Of course. Or at least when her first set of markers came back. I am just not used to treating MIs with lytics. Coming from a large metro hospital with a huge cath lab, the only time I see lytics used for MIs is if the patient is brought in from a rural hospital. They are proper treatment, though, if a cath lab isn't available.

As for the lactic acidosis, it is very ominous for heart patients. I'm not sure what your docs meant by there being three different types of diabetic acidosis, but high lactate levels are dangerous. In this case your patient was getting a double whammy. Ketoacidosis uses up bicarbonate which creates the initial acidosis, but the compromised myocardium also wasn't efficient at pumping the blood to get oxygen to the tissues, creating an anaerobic state. Anaerobic glycolysis only produces 60-70% of the energy of ATP and reduces a muscles ability to maintain the sodium-potassium pump. Sodium builds in the cells reducing the amount of calcium that can flow in and increasing the outflow of potassium, decreasing contractillity, which decreases the heart's ability to get oxygen to the tissues. The potassium leached from ischemic tissues causes hypopolarization which leads to calcium shifts which may lead to disrhythmias.

Glycolysis also leads to an increase of lactic acid, which worsens the acidosis already present from the ketoacidosis and continues the above vicious cycle. Acidosis will further increase the damage to the heart by making it more vulnerable to damage from lysosomal enzymes.

Is that sort of the answer you were looking for? I'm on a different sleep schedule right now, so I'm not sure if I'm making sense.

One thing I love about this BB is that I am able to continually learn. Believe me, I didn't spit all that out from memory ... people ask questions and I go right for my books and look it all up. Hopefully, in the research and explaining, I get to learn more too. :) I've only been doing this for three years, so if anyone has something else to add, please do!

[J_W, DNP, APRN, CNS]

I would be curious what the serial 12 lead EKG showed if they were done. Given her symptoms, and labs, with 12 lead that shows acute infarct, etc. As an ex-cath lab nurse I would say she probably should have went to cath lab sooner, you mentioned fellows/residents, I take it that this is a teaching hospital, in which case the cardiology fellow should have discussed it with the attending on call....Oh well...Just what I think..

[VickyRN, MSN, DNP, RN]

Yes, there were acute changes on the EKG suggestive of a MI, along with sky high MB's and troponins which were trending upward. At one point, not only the resident, but the fellow and an attending were in the room with the patient. At least at 4AM, when new labs showed troponin trending upward, they should have taken her to cath lab, IMHO. Perhaps they were thinking that the TPA she had received in the outlying hospital may have cleared her coronaries; but with her increasingly acute symptoms, don't understand why they did not take her to the cath lab sooner. Like I said, I am only 5 months on the unit and lack experience. Next time, I will be much more aggressive in "suggesting" that the pt go to cath lab ASAP!!!

[VickyRN, MSN, DNP, RN]

I have another question--this lady did not know she was diabetic; no prior history. Her husband, who is diabetic, decided to check her blood sugar the night before, as she was feeling so bad. To their shock, her BS was 400! I THINK I have read somewhere (have read so many articles, books, seminars, etc., can't keep track...) that when one is having a particularly nasty MI, high blood sugars may also result, even when one is not diabetic. Something to do with all the damage going on in the cardiac cells. Anybody familiar with this, have any info or light on this to share, or am I just imagining I read this somewhere????? Perhaps her true MI started 2 weeks ago with the GERD symptoms which wouldn't go away, cardiac cell damage in turn causing the sky-high blood sugar, worsening MI beginning to extend, causing fresh elevation in MB's, shortness of breath, weakness. (LFT's would show if MI had been going on for awhile--LDH, especially.) Then, the beginning of cardiogenic shock, resulting in very high lactic acid levels due to tissue hypoxia and anaerobic metabolism. I read in my copy of the ICU Book that a lactic acid level of 10 accompanied by a clinical shock state forecasts a 100% mortality rate!!!! Didn't know this was so serious--no wonder the charge nurse was freaking. Going back to work tonight, so I will find out how this patient is doing (hope she is still with us).

[live4today, RN]

FYI: See MickeyMomRN's thread on the Cardiac Forum titled "Need answers about cardiac" and you'll see another person who posted there also talking about how women are misread when it comes to s/s they have compared to men in cardiac distress. Glad to see that I wasn't the only one mentioning this scenario that is often played out in the healthcare system when it comes to diagnosing female cardiac problems, etc. Our docs still have much to learn when treating and recognizing symptoms females have.

[JustMe]

Women across the board are short-changed in our health care system, especially if they have heart disease because they do not present with classic symptoms. Of course your patient should have gone to the CL sooner because she continued to be symptomatic--and that does not necessarily include chest pain because she didn't PRESENT with chest pain. Even though we do interventional cardiology, we still give some patients 'lytics and if their symptoms are not resolved then they go to the CL. 'Lytics don't always completely resolve the clot, depending on the time frame. And this patient had been symptomatic when she saw her first doctor. I had an interesting patient one time who was a 40-something Black female who called 911 with SOB. The male paramedic thought she was just hyperventilating and didn't want to take her in. The female paramedic thought something was probably wrong and insisted they take her to the hospital. Guess what?? She was having an MI!! So it's not just the male docs who short-change women in health care!!!

[live4today, RN]

Thank God for that female paramedics gut feeling that something just wasn't too kosher there with that patient, or she could have died. The male paramedic was probably just going on what he was already familiar with when it came to which symptoms to look for when a person is having a heart attack. This only proves that the health professionals as a whole need to be schooled on the various s/s that may be noted in women versus those typically noted in men when assessing them for an MI. :)

___________________________________________

"Just when you think you've graduated from the school of experience, someone thinks up a new course."-- Mary H. Waldrip

[KRVRN, BSN, RN]

When I did an ER elective one time a middle-aged female pt came in with back pain and stomach upset/nausea. The resident wanted to give her a GI cocktail and see how she does and the ER nurse (with many years of experience) wanted to do an EKG first. The resident questioned it and said it was unecessary but the nurse insisted. (yay nurse!)

...turns out it really was GI-related.