Cardiac question???

[Nicky30, BSN, RN]

I have been nursing for about 14months and have only just started some shifts in the ER (small country hospital maybe up to 10 patients through on a weekday day shift).

We have been having an unusal amount of cardiac patients come through our doors of late (or maybe I'm just lucky and they come through when I'm on lol).

My question concerns bradycardia.. and I would be grateful if anybody can shed some light on what these patients are experiencing.

#1 Elderly patient feeling faint called ambulance comes in with HR of 26 (can't for life of me remember sats). After some atropine it came up to (60 something). No chest pain etc. just feeling faint (I don't recall them mentioning that they fainted).

#2 Younger patient presents with chest pain lasting approx 30 min (did not feel faint) HR 38 sats 95%. Nil medication required other than O2 as HR stabilised and went up to 51 (normal for them apparently). This patient also on sodium channel blocker for intermittent AF.

Not sure what happened to these patients after they left my department.

My question is this: Why has the second patient experienced chest pain when their HR is faster? At what point does the bradycardic patient feel faint (if at all I guess)? In your experience how long does their slow HR need to be sustained before their sats drop oh and how low have you seen a bradycardiac pt's sats drop?

Thanks,

Nicky.

[Conrad283, BSN, RN]

Chest pain is experienced when there is a lack of oxygen to the heart tissue ... ischemia. It sounds like the first patient simmply had a vaso-vagal reaction to something ...

Bradycardia will cause fainting when there is an oxygen deficiency to the brain.

[GilaRRT]

Let me see if I understand your question? You want to know why the younger patient had chest pain even though his heart rate was faster than the older patient. The answer is rather complicated. You need to consider underlying medical problems, medications, perception of pain, and several other factors. For example, a diabetic patient may not even have pain and yet experience a massive MI. However, both patients were symptomatic and perhaps that is more important than focusing on pain alone.

The second part of your question: Pulse oximetry is but one tool to help us gather information. Remember, you can be in profound hypovolemic shock or experience severe carbon monoxide poisioning and have a great saturation, or you can come in from a run outside and have cold hands and a very low saturation by pulse oximetry.

Remember, the problem with symptomatic bradycardia is loss of cardiac output. As we know, cardiac output is related to two concepts. Heart rate and stroke volume. Some people can tolerate very low heart rates because they have great stroke volumes. Athletic people for example. Other people, will be very sensitive to changes in heart rate, because they have poor stroke volumes. So, a static number will not apply to every person.

[Nicky30, BSN, RN]

Thanks GilaRN, it makes a bit more sense. I basically knew all of those pointers you mentioned, but I don't think I was breaking down individual components of the problem. I.e. pain perception.Does anybody else have anything to add?Nicky.

[Medic2RN, BSN, RN, EMT-P]

What did the 12 Lead show on the patients? Could Patient #1 have had a Mobitz Type I heart block?

Patient 1 was elderly. Due to the aging process, the elderly typically have a muted response to pain. Other patient populations that may experience symptoms other than chest pain are women and diabetics.

There are many variables missing, just doing some guessing!

[Virgo_RN, BSN, RN]

Remember that cardiac chest pain is related to myocardial ischemia. That is, the heart muscle itself is not getting enough oxygen. There are other types of chest pain, such as that caused by a pulmonary embolus, musculoskeletal pain, or epigastric pain.

The patient in scenario 1 was feeling faint because his cardiac output was so low that he wasn't getting enough oxygen to his brain. As we age, blood vessels lose elasticity so that the normal response to a low CO (vasoconstriction) would be impaired.

In scenaro number 2, the falling CO would cause systemic vasoconstriction, preserving circulation to the head. The patient may experience chest pain related to coronary artery spasm related to the systemic vasoconstriction.

More than their SaO2, I would want to know their blood pressure. This would be a far more telling indicator of perfusion to me.

[Noryn]

Ultimately you have to avoid getting hung up on numbers. A lot of the times they dont mean a whole lot. The more important thing is how is the patient doing. Not only with cardiac but almost with anything because your body adapts.

A non compliant diabetic, you put their BS at 80 and they are likely going to be sick. When I was 18 my blood pressure often ran around 90/50--yet that same pressure can cause someone to have syncope.

Elderly often develop bradycardia and in my experience the number one effect is fatigue. Often it comes on so gradually that they dont realize anything is wrong but once they get a pacemaker they cannot believe how much better they feel.

[Nicky30, BSN, RN]

Thanks for helping me out, it was hard to ask my questions because I could not remember so many specifics (after a while all the patients seem to have the same issues and their VS all meld into one lol).

Of course it could just be my brain which is having trouble remembering my name on a good day.

I agree it's easy to get stuck on the little numbers on that monitor and that sats wouldn't necessarily correlate to cardiac ischemia therefore pain experienced. And like Nancy posted the pain could have been due to any number of things. The older patient (which I saw probably about 4 weeks ago) was in their 80's and on a bucket full of meds (not that I remember any diabetic ones).

Interesting... thanks again, will be thinking about this all day now (on my day off lol).

Nicky.