Atropine

love-d-OR · Sep 8, 2008

Okay, so I did a little e-research and it seems he was referring to cushings triad: increased BP, low HR and widening pulse pressure. He had the first two but not the widening pulse pressure. Also, the article I read stated that cushings triad is usually seen in the late stages of CE or increased ICP. Again, thsi gentleman had no neurological signs of an increased ICP.

joeyzstj, LPN · Sep 8, 2008

We usually give it if the HR is less than 35-40. You have to look at the overall situation. A lot of 3rd degree heart block patients will have a HR of 35 and a blood pressure of 190/80. It something to keep an eye on. I usually will give a half an amp of atropine which works most of the time.

Soonstudent · Sep 8, 2008

You are right Love, only give it if the pt is symptomatic. It can be a little nerve racking to have a hr around 30-40, but if the pt is compensating accordingly no need for meds. However treating the cause if in fact it was elevaed icp's may be an option. It sounds like he could have had increased icp's. Agitation and change in LOC are classic signs.

If you have a pt in complete heart block you need a pacer. Antropine works on the SA node, and since there isn't any comunication between the atrium and ventrical you could cause more trouble. Another interesting note that I just learned is atropine isn't affective in heart transplant pt's because the conduction system isn't intact. :)

love-d-OR · Sep 9, 2008

Thanks for the replies guys. He was actually 'sinus' during this episode, we expected him to be junctional or have some sort of block, but his wave lenghts were all WNL. Cardiology said they were suprised it was SR at such low rate, so they said to watch.

Anyway, he is since doing well. HR and BP very stable, and LOC had no change from the previous day. CT scan was negative for bleeds or edema!

Soonstudent · Sep 9, 2008

Yea some people just have really low resting heart rates. Lance armstrong is in the 30's I've heard

Critical_Care_RN · Sep 12, 2008

I had a patient who had a very low heart rate, between 37 and 45. Heart rate hung around the 40's most of the day. His blood pressure however, was about 160-190 systolic. We fixed the heart rate and blood pressure by the end of the shift, with a mix of HD, hydralazine, and enalapril. He was also on a versed drip for agitation, and it helped the BP.
Anyway, my question is when do you give atropine? I know it is given for low heart rate but how low is low? I thought my pt's heart rate warranted some atropine, but I was told to hold off if he maintained his blood pressure, which he did so I never got o give it. Does that mean that atropine should be given if the patient is symptomatic and his/her VS are deviating from the baseline? This patient was sedated and very unresponsive, would the BP be the only thing to guide me?
His HR really worried me, I did sternal rub a couple of times and it helped fix the HR for a little bit. One of the MD's suggested it may have somnething to do with cerebral edema (we went for CT scan, no results by end of shift. Pupils reactive). I was too busy to sit with him and pick his brains, anyone care to explain?
All answers are more than welcome, thank you in advance.

At our facility, we only give the atropine if the patient becomes symptomatic. ACLS guidelines also only call for giving atropine if the patient becomes symptomatic. Symptoms of bradycardia might include fatigue, shortness of breath, dizziness, chest pain or palpitations, hypotension, confusion, or syncope. Obviously, if the pt is unconscious R/T some other disease process, he can't tell you if he's having these symptoms so you have to make the judgement based on the objective S/S. In this case, you'd have to rely heavily on the patient's BP.

love-d-OR · Sep 12, 2008

I want to take ACLS, but my assistant manager told meto wait 6 months. I have already being involved in a code, and I was told I did good, and if I had ACLS it would not be much different. I don't know...I'll wait, but I think they should make it mandatory for every nurse. Thanks for the replies everyone.

MBCRNA · Sep 14, 2008

Just as others in the previous posts stated, you really look at the overall picture. But to put a number to your question, I don't believe I have every taken care of anyone that was below 35 consistantly without pacing or giving atropine. There are many reasons why the patient could be having sinus bradycardia. If he has a history of hypertension, maybe he received quite a few meds and was possibly taking the toll on his rate. Cushing's triad does cause bradycardia, but It is a VERY LATE sign...herniation of the brain. There is a possiblility his conduction system was playing out. Generally speaking heart rates of less than 35 (unless an athlete) cause symptoms. If it was Sinus bradycardia, atropine will work. Like a previous person stated, a patient with a heart transplant doesn't respond to atropine due to the denervation that occurs with transplant. Isuprel is used in this case. BP isn't the only sign that you'll get with decompensation. You might see chest pain, dizziness/syncope, decreased mental status, shortness of breath, low blood pressure, etc. Was the 35 hr the cause of the decreased mental status hence CT of the head or was it a result??? Sounds to me that patient might've done better if atleast set to a demand of pacing for less than 35...But in my experience, my order I would receive would go as follows:

Atropine 1/2 amp for HR

love-d-OR · Sep 14, 2008

The resident and a fellow from cards were both standing next to me when his HR went down to 35. I was ready to give the atropine, but was told to wait until BP dropped. This guy was intubated and sedated from post sugery the day before. CT was done because they wanted to rule out any possible neuro cause, so no his LOC was same (only responsive to deep noxious stimuli)

suanna · Sep 14, 2008

There are OODLES of reasons for a low heart rate just as there are for a high heart rate. If you are correct that it was NS/SB artopine may have helped his rate for a few minutes, but it is a short acting, emengent situation drug. Artopine is used if the patient is symptomatic and if you do use it you need to pe prepaired to go to another drug to mantain the heart rate when the atropine wears off (dopamine, epinepherine, dobutamine... Some patients don't require anything but the atropine if the cause of the brabycardia is vagal, but then again most vagal episodes resolve on thire own before you would have time to "fix them" with the atropine. Watching a heart rate in the 30s and 40s is VERY stressful, but the soultion to this patients bradycardia was finding the cause and treating that, not providing brief vagolytic intervention unless there is an acute change in the patients LOC or VS requiring immidiate intervention.

lifeLONGstudent · Sep 15, 2008

my thoughts:

HR of 40s - not pretty, but how is your patient? Does he look grey and dead, or NOT? Good peripheral pulses -- perfusing all tissues? then leave it alone. Good pressure - leave it alone. You mentioned pressures were fine, even high. This about what is happening. Think about hemodynamics: Heart is in sinus, and just reallllllly slow. So there is a LOT of time for the chambers to fill, you are getting a really good stroke volume and hence a good pressure. He isn't low on volume, so good preload --> good pressure. Contractility a problem? Doesn't sound like it. So, if you speed up a sick heart (and I say sick because most hearts don't beat 30 x minute -- so it is either sick or professional athlete healthy [doubt it is #2]).... speed up a sick heart, which is doing it's job just fine, just to make it "normal"... then you are going to screw yourself and your patient. Basically, don't fix what isn't broken -- and right now, it is working ok.

So what would happen to his BP if you gave some atropine --> probably go way higher.

You mentioned cushings and that you found out this triad after you looked it up. I am not bashing you, but I think this is basic knowledge for any ICU nurse and should have been covered in your training (or at least school - I cannot imagine you never covered this in school). Waiting 30 minutes for a CT read is also not acceptable. Your ICU docs should have looked at the CT... and then called radiology. If the pt was exhibiting signs of cushings, then he had a high risk for herniation and interventions would be warranted -- and sternal rubbing a pt with pending herniation is not a good idea. As you probably know.... high ICPs need HOB 30 degrees, MINIMAL stimulation (suction, turns, agitation, keep nice dark/quiet environment, ADEQUATE sedation, ICP monitoring and management) and maybe some mannitol or 3% NaCl. If the docs mentioned cushings... these COULD be life saving measures.

I would have put on pacer pads -- just to get ready :-))

So, these are my thoughts. I work in a medical ICU (not cards, not neuro). Others with more specialty might have more insight.

I think you are doing a good job by looking up more info ... you are responsible for you now (no professors encouraging you to study). Take all the free classes you can. GET ACLS (press your manager) and they say no, get the books from AHA and start studying on your own. Buy some CCRN study materials -- that will help you alot (not for the exam, but for everyday when you work). Read about ALLLLL the drugs you are giving. Pick your peers brains and absorb all you can from rounds with your docs. These are some of the things that will make you a good nurse.

Happy learning,

LifeLONGstudent