Res. c/o right side chest pain + SOB. Pale, diaphoretic BP 120/60 P 160. Pulse elevated about 100 points BP WNL. SPO2 low 90s. No cardiac history except for chronic hypertension managed with several anti-hypertensives. No RX for NTG prn angina. Dxs CVA, Parkinson's, seizures. Breath sounds equal bilat. fine crackles to diminished bases. Alert, oriented per usual in distress. O2 started 4LNC. SPO2 coming back up quick. Sx continue.
We elected to not give nitroglycerin d/t possible additive effects with the anti-hypertensives causing hypotension with reflex tachycardia possibly resulting in a worsening of the rate. We were ready and willing to give it anyhow if the situation worsened but we called the paramedics right away, got her to the ER right away and she got some cardizem which made it all better followed by a week in the hospital with a few bouts of dysrhythmias.
Now the question is - when to not give NTG with chest pain.
Keep in mind that we are a nursing home and we have no cardiac monitors, IV access, drugs other than PDOs and Standing Orders (Which includes NTG for chest pain). The only doctor we have during my shift is the on-call who more often than not has no idea who we are talking about over the phone.
I read somewheres that a normotensive pt. with newly emergent angina and HR>150 should not get nitrates. I understand the protocols do not specificaly call for NTG but neither do they contraindicate it. It seems like a gray area or splitting hairs or maybe an area for splitting gray hairs. This is for future reference.
Last edit by MikeLPN on Mar 19, '04
Mar 19, '04
I am no expert on this. However, I am working i a tele unit. We would have an order for ngt. and we would give it in this case.
I understand what you mean about reflex tachycardia. And this is my take on it.
If nitrate induced vasodilation occures rapidly then the heart may falsely sense there is a dramatic loss of blood volume and speed up to move the smaller volume more quickly. then the heart soon realizes there has not been a loss of volume, but the missing volume in the heart, is in the periphery and the heart automatically retuns to a normal rate.
As I said I am no expert but I am not aware of a protochole to not give ntg. with chest pain. The only possible time it might not be given is in severe hypotension.
The normal BP that you mentioned is not and indication to withhold Ntg.
Unfortunately you did not have an order for it. What a delimia for you. Perhaps, you might discuss getting standing orders for all patients so that when this emergent situation happens again you are not left stranded.
It sounds like you did the right things in this case. You got O2 on her, and got the paramedics to take her to the ER.
My guess is the chest pain was eschemic second to a tachdysrythmia. (160 is not sinus tach) the O2 sat was on the low side as the heart was working so hard (<-my guess) or could be the other way around.
it is hard (for me) to say if ngt would have made a difference or not. It is unlikely it would have done any harm. IMHO
I am interested to see what wisdom there is on this from more knowlegable nurses.
Last edit by Agnus on Mar 19, '04
Mar 19, '04
Ill give this one a shot!..I think it was wise not to give nitro, especially with no IV! In the ED we must have a IV acsess. Tends to get u out of sticky situations.
The main problem is that Rate...Either SVT or AFib RVR (Awesome picture painted with the crackles in the bases). This is usually fixed with adenocard or cardizem. The pt was maintaing a BP but that could easily changed..the lung sounds point to a pump problem (rapid heart rate).
These are some of my fav. pts., they come in diaphoretic, cp..rapid heart rate and are usually converted with the adenosine or the cardizem..very rarely cardiovert. if they convert they tend to go home if the enzymes are negative.
Mar 20, '04
I've tanked a lot of BP's with nitro. Usually it's the beginning of the end and I call for orders for ASA NOW (depending) + MSO4 if there is time
The nurse I was with (who's wing it actually was) is really experienced in LTC. We just looked at each other and pretty much said "You know what's going to happen, we give her NTG, her BP drops and all we can do is stand there and go OOOPS!" She was young ('60s) and had a chance, she was on a bunch of BP meds and a fairly complicated hx besides. Her husband is sitting right there and they are both just so nice to us.
I guess my question is about ACLS + NTG in this situation. Like I said we were SO ready to give it but we held ourselves back just on intuition mostly. We were right in the end (I think) and things turned out really well for her. I was just wondering if there was any hard and fast justification either way
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