I was working in ICU the other night (technically as a float nurse, although I was given a patient assignment), and was receiving a patient from the ED. He was in his late 70s (78, I believe), and resided in a skilled nursing facility. The patient had a past history of HTN, hyperlipidemia, dementia, CHF, renal failure, MI X 3, CABG X 2, two cardiac stents, and DM. Apparently, he had been in the dining room at lunch, had become cyanotic and hypoxic, and was rushed to the ED with sats in the 70s.
The patient was placed on BiPAP, a CXR was done, and labs were obtained. The blood gas, of course, wasn't great. The patient was in respiratory acidosis with a pH of 7.1 and CO2 in the 60s. CXR revealed a left lower lobe infiltrate. Initial troponin (drawn at approximately 1330) was 0.142. The patient received a one time dose of Levaquin in the ED, but the admitting physician decided not to continue antibiotics in ICU because she felt that his WBC of 8.2 wasn't indicative of infection.
When the patient arrived to ICU (at approximately 1946), his troponin had increased to 2.44. The ED had noted evidence of a lateral infarct on his EKG, but could not determine the age of said infarct. Vitals were stable, and he was in normal sinus rhythm. After a few hours, however, his BP began to steadily trend down. It got to as low as 90/37 before stabilizing. Heart rate also began decreasing (although I feel that this occurred as the BiPAP was optimized, his gas improved, work of breathing eased, and he became less anxious).
I inquired with both the ED and the charge nurse about the acutely elevated troponin in someone with such a cardiac history. I also asked about whether it would be prudent to start antibiotic therapy on an elderly patient with a known infiltrate on CXR. I asked the charge nurse three to four times about whether or not the physician needed to be called. No one else on the unit acted like it was a big deal, but I was greatly concerned.
The patient denied chest pain, however he did have advanced dementia. I don't know that this was reliable information. I was pulled to another unit at 0400, however, I did see his 0600 labs. By 0600, WBC had increased to 18.2, potassium was elevated at 5.5, creatinine and BUN had both further increased (although he had a history of renal failure, and was dehydrated). Troponin had increased again to 2.568. The blood gas was much better, and had almost returned to normal, but that was the only thing that looked decent.
I realize that CHF and pneumonia can elevate the troponin. However, the BNP was 73, and the infiltrate noted on CXR wasn't especially large. I know that a PE can also elevate the troponin, however this patient showed no signs of a PE. I feel like the troponin was truly an indication of cardiac damage, and that treatment did not reflect this.
I just wonder if I, personally, could have done anything else, or if maybe I made too much of a big deal out of his condition. No one else in ICU seemed concerned with anything, and I felt like my concerns were very minimized by staff. Did I blow this out of the water, or was I justified? And what would you more experienced nurses have done if you were in my position?
