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Cardiac Markers and stress test

Has 35 years experience. Specializes in ICU,ER,med-Surg,Geri,Correctional.

Okay folks pardon my lack of knowledge and it's true that this old dog has a prblem with some of the new tricks. I had a 42 yr female pt HX: Woke out of sound sleep with chest pain, mid-sternal with +rad down left arm, no SOB,no sweats,+aniexty,+N, +Vx1, Inspite of the pain performed her daily exercise, went to work. the pain returned,she went to ER tx with NTG sl and Morphine, sent to Chest pain unit. Then all the markers CPK,Trop all normal, EKG normal, she had stress test and about 10 min in chest pain, had to stop test, given IV morphine pain stopped. 2 hrs later sent to my Med-Surg unit. This lady BTW when she mentions exercise she claims that she claims that about 3 days a week she does"100 sit ups" this seems to me that she should be in good conditionj and I would suspect her to beat the clock and ace her stress test. Okay she calls me with c/o chest pain about 3 hrs after she is on our med-surg unit. I was impressed with both hx and her presentation. I got an EKG stat, gave her a NTG sl with no change, EKG WNL, gave morphine and settled her down. My younger co-workers gave me the impression that I was in an overkill mode and went overboard since she had "normal stress" which I find debatable to my way of thinking, and the neg cardiac markers. I am an old Cardiac nurse and still remember the normal stress and even normal caths then came back DOA in the old days. Should I have been content with all these "Normals"? Don't laugh in my CCU days I was really good at these things. thanks

angle71054

Has 13 years experience. Specializes in CCU, med/surg (cardiac/tel).

Speaking from as CCU nurse with 5yrs under my belt here. You can never have "too much over kill". We can do all the tests in the world CK,CPK,CKMB,trop I,EKG, stress tests everything and you still don't know the whole picture. Just because we haven't seen any signs of changes doesn't mean there isn't something going on. I have even seen pt that come back from a clean cath and have chest pain after. The pt could be having spasms or have developed a lot that has lodged in one of the cornary arteries. The moral of the story is if in doubt "CYA"(cover your a**). I would rather be safe than sorry and I'm sure the pt would agree.

dnnc52

Has 35 years experience. Specializes in ICU,ER,med-Surg,Geri,Correctional.

Thanks Angel: I thought as soon as they gave me report that this pt has a strong chance of having prizmental angina which is usally the result of a coronary spasm, since woke up out of sound sleep. What I am not up to in my cardiac knowledge is about these new trop markers. I know that you can actully have clean pipes and still have spasms and that they could have stone cold normal caths. first off in the old school any pain R/T the stress test would have usually indicated a farther work-up, and certainly not a transfer to a non-monitored med-Onocolgy floor, just a few hours after the stress test. But that was like I said many years ago in my CCU days and trust me things and ideas have really changed. So I enjoy getting to network with the more younger and up to date nurse on this board.... thanks

reisling

Has 20 years experience. Specializes in med surg, ccu, icu, nursg home, md offic.

I'm pretty sure you can have clean coronaries with Prinz Metal. I would def air on the side of caution and treat her like she is having angina.

lkwashington

Has 4 years experience. Specializes in Tele, ICU, ED, Nurse Instructor,.

No, always go with you gut. An overkill is better than an no kill. The reason why I say this. A man in his 50's had a cath post two days had a nodule in right groin. md notified...nurse offered some suggestions. md didnt bite. patient coded with a PEA related to hypovolemia. The patient HGB went from 11 to 6. ct done..patient bleeding in different orifices. patient needed PRBC's, plts, and plasma. You tell how would you have handled this situation. Just a thought.

dnnc52

Has 35 years experience. Specializes in ICU,ER,med-Surg,Geri,Correctional.

I would have consider this pt to have DIC. I would take advantage of this new team we have the rapid response tteam, according to what I am told they have all kinds of orders they can implement without the MD pressence.

lkwashington

Has 4 years experience. Specializes in Tele, ICU, ED, Nurse Instructor,.

A registered nurse can run a code for the first 8 to 10 mins without a md present.

Questions to consider asking....

Were there any ST/T wave changes during her pain episode? Any arrhythmias?

What type of "stress test"? Chemical, non-chemical, which chemical?

If she can't finish the test secondary to same, and excluding any mention of the above, it would seem that an "elective" cath would be in order. Then you could check her for prinzmetals with ergometrine.

If everything is normal/negative...then move on to ruling out other causes.

aerorunner80, ADN, BSN, MSN, APRN

Has 8 years experience. Specializes in MSN, FNP-BC.

I was wondering if the stress test was chemical too. If she had a 201 done, that will indicate angina and the tech-99 will tell if she has had a previous MI.

I don't think you went overboard at all. I would have done the same thing, especially knowing her past becuase even if it is angina with a known history, that doesn't mean that it wasn't an MI this time.

So this pateint wasn't on a tele/SAC unit at all? That's scary knowing her history!!!!

dnnc52

Has 35 years experience. Specializes in ICU,ER,med-Surg,Geri,Correctional.

well she came to me from the tele unit, but then was transfered to our unit 2 hrs post the stress test. Which I assume was the usual trendmill without chemicals, since she was considered to be in good shape. BTW the ouitcome was the next day had a EGD found mild GERD sent home on Prilosec. Still I feel oaky about my intervention. However the next day I had an out pt get 2 units of PLTs and upon discharge was rubbing his chest. Called his MD sent the guy to ER and then he ended up with an acute MI. Oh well it's always a roller coaster ride in this type of nursing... thank all of you folk for the share!

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