Had a rough shift...need some input please!

[al7139]

Hey all,

I haven't started a new thread in a while, but had a tough one last shift.

Got in at 3pm, got report. Great, only 5 pts to start, 4 who were doing fine, and one new admit who had just arrived to the floor (all new admit stuff done, just need to go say hello, assess and monitor). This new pt came from the ED, had been there most of the day. Hx: Hypothyroid, back surgery, foot surgery, had SVT 5 years ago and was cardioverted. Presented for SVT, cardioverted in ED (under sedation). In ED got lots (don't remember how much) of morphins and ativan and some cardio meds. Pt stable, admitted to our floor on tele. HR at start of shift 78, SR. VS good. Pt is a walkie-talkie. Young 41yo F. Husband at bedside. Go in, say Hi, do assessment. Pt appears relaxed, and normal. Have meds and scheduled cardiac enzymes to draw. first two sets WNL. Scheduled for 2DE with bubble for next day. Pt eats dinner, still OK, meds given, still fine. Not 10 minutes later, called to room for pt. Tele calls at same time...HR 180-190 sustained, pt hyperventilating, tells me she has CP and pressure, convinced she is dying. Call ClinII to room (I'm new grad...need help!). Ask for NA to get VS and EKG. Try to talk to pt who is so far into panic that I can get no response other than "Somebody help me!" Unable to get EKG or VS since pt is so tense and shaking. We look at orders...NO IV meds ordered for anxiety or pain, etc. Page MD on call TWICE with no response. Meanwhile, husband and sister (who just showed up) are yelling at us to DO SOMETHING! OK, so I get right up close to her and try to talk her down (Seen this before (my mom has a panic disorder)). No help. We start SL nitro in the hopes that it will ease the chest pain/pressure. Gave 2 doses, but had to hold third as BP was 99/80. Finally get MD on phone who gives orders for IV Digoxin and Ativan (2mg IV), call cardiology, and transfer to PCU where he will see pt. WHAT!!! We really could use you at the bedside now doc! Could you please grace us with your presence? It will take us a while to get her to PCU. Call cardio, they call back and give us prn lopressor orders and amiodarone bolus/drip orders AND take her to ICU. Ok great, can do, but she is still in a severe state of panic...can we do more sedatives??? No orders for sedation received. OK, pts bp now 228/110 and pulse at 187. Pt is diaphoretic, hyperventilating, and crying for help. Finally first MD paged shows up, and asks for a paper bag. Pardon my french but ***!!!!???? I realize that in mild or moderate panic, this can help, but we are WAY beyond that! Ok get orders for 10mg valium IV. Give it. Pt still panicky. MD talks to family who we have finally gotten out of the room. Comes in. Pt says that she is going to die, and is scared and crying and cannot stop hyperventillating. Get orders for 10 more mg of valium. Ask my TL to get itafter checking vitals to make sure she is ok for additional dose. She is concerned about giving so much valium, but at this point, pt is stillso panicked I don't think it's an issue. After all they give pts way more than this at times. After a total of 20mg valium iv and fluids, and bolus of amio, pt finally is calm and rational again. She insists that she is not having a panic attack b/c the cardiologist in the ed cardioverted her. OK, whatever you want to believe os OK with me, I know that b/c she panicked it made the situation much harder to deal with. Started amio drip, and transferred her to ICU for close observation.

Now, I am not unsympathetic to panic attacks having had a mom who had them and having had a couple myself over the years, but this was a tough one to handle for a newbie nurse. In spite of her high b/p's and pulse, I knew she was probably not going to die on us, and what she really needed was heavy sedation and possibly some psych meds in the future to prevent serious panic attacks from occuring. Her family swore she had never had any issues like this before. I spent 3 1/2 hours in the room trying to talk her down and felt like I had been there for 24 hours. I needed valium after that (just kidding!). Are there other things I could have done? She was in such a state that she would not listen to me whan I tried to help her breathe, etc. I think the family being there made it worse, but we couldn't get them out of the room. Any advice in how to handle this in the future? I just kept trying to reassure her that she was not dying and that I would stay with her and make sure she would be OK. Could I have done more?

Thanks,

Amy

[steelcityrn, RN]

Under those circumstances, that woman in severe anxiety/panic would only respond to medications. There would be no way you could have gotten her to comply with purse lip breathing. She was way beyond that. Maybe calling a code would have helped everyone, but I think you did fine, was working under great pressure and f/u on orders quickly.

[al7139, ASN, RN]

Thank you all for your support and feedback. I am so new at this that sometimes I feel like I never went to school! Good to know that I did the right thing.

We did call our Medical Response Team to the room, but they werent much help. They can be called for any change in a pt that we feel is beyond us, but not quite a code. Usually its an ICU RN, an RT, and the Patient Care Supervisor for the hospital. THey in turn can run codes, call anesthesia, MD etc. if need be. We had called the md , but it tok us so long to get him to show up and give the right orders. How frustrating! I was practically yelling into the phone "I don't think you understand! I need sedatives as well as heart meds!" My research indicates that an overabundance of thyroid hormone can cause her arrhythmia, as well as severe panic attacks, so it's hard to tell which came first in this situation. I agree that it was a life theatening arrhythmia, but heart meds alone were not enough.

There was no way I was leaving the room for anything, so I had another RN pulling meds for me. She was totally relying on me for reassurance and trusting me to get her through this...How could I leave? All I could think was my instructor in school saying never to leave a pt in trouble, and get someone else to fetch and carry for you. Thank God our unit is a tight team who will help you out when you really need it!

And yes, after that I was really spent! I swear I felt hung over the next day when I woke up! Probably all the Adrenaline!

Amy

[BBFRN, BSN, PhD]

http://www.emedicine.com/ped/topic2247.htm

Here's some info on thyroid storm.

[al7139, ASN, RN]

Thank you to Baptized by Fire for that link. Although it was mostly pediatric info, it was still helpful. I also looked up thyroid storm in my textbooks from school. After this patient, I will always be alert to the potential for problems with anyone who has a history of hyperthyroidism or recent thyroid surgery. After reading up on it, I can see that while it's hard to tell which came first (the panic or the arrhythmia), it's probably the arrhythmia that caused her panic, and then it just cascaded from there. Luckily, she finally got what she needed to help her and did fine.

Amy

[BBFRN, BSN, PhD]

Yeah, I should've provided a better link :). Another thing to consider with your thyroid patients is hypocalcemia. I have seen dysrhythmias with sx's of anxiety mostly in hyperthyroid patients who are hypocalcemic.

[jmgrn65, RN]

I am concerned that your MRT kept saying it was a panic attack and what were they going to do. Well lets see treat the symptoms, hr over 180 a rapid response team should have protocols that have meds for tachy and for the high bp. She was paniced because of her hr duh!

I think the poster did everything right. good job

[Virgo_RN, BSN, RN]

Forgive me, but I'm not understanding really well. You are on a telemetry unit but it's not a PCU? Your floor has no protocols for SVT?