How woud you treat this patient...

**NICU Guy, BSN, RN** · May 15, 2016

How about tell us how you would treat first, then we would give you input.

zzyzx · May 15, 2016

I'm not entirely sure, which is why I'm asking, but probably I would do this initially:

1) give Versed and Fentanyl

2) pace him

This is complicated because he's brady, yet also very hypertensive, very anxious, and having chest pain. I would hope that by pacing him the PVC's (the bigeminy) would go away. I would consider atropine, but that is something that can't easily be turned off if it makes things worse, so it seems like pacing is a better approach if the patient could be made to tolerate it.

FYI this is a patient that I did not have but was told about. The patient had had a history of MI's in the past and was having crushing chest pain.

Emergent, RN · May 15, 2016

Why would you pace him? Makes no sense at all with a bp that high.

I would get monitor on, O2 on, and start an IV immediately, if this is in ER. Cardiac protocol will be ordered, Dr will likely want to start with SL nitro and 324 mg ASA. BP is first concern, plus diagnostic results.

offlabel · May 15, 2016

Agree with above post, I'd add Morphine.

ixchel · May 15, 2016

This person needs labs and more assessment data. Treatment plan depends on that. Cardiac protocols will dictate MONA, but next -

Kidney function?

Lytes?

Cardiac biomarkers?

What makes the CP worse? Better?

Do they take beta blockers?

Repeat BPs?

EKG?

What where they doing leading up to this?

Does therapeutic communication calm them?

What is the priority here? What is the most important problem (especially if you don't have labs or anything on this person yet)?

offlabel · May 16, 2016

This person needs labs and more assessment data. Treatment plan depends on that. Cardiac protocols will dictate MONA, but next -
Kidney function?
Lytes?
Cardiac biomarkers?
What makes the CP worse? Better?
Do they take beta blockers?
Repeat BPs?
EKG?
What where they doing leading up to this?
Does therapeutic communication calm them?
What is the priority here? What is the most important problem (especially if you don't have labs or anything on this person yet)?

The point here, I think, is to stop this patient from dying so that you can do all of those other tests.... we're talking about 15 minute intervals here. O2, IV, NTG, morphine, move forward.

ixchel · May 16, 2016

The point here, I think, is to stop this patient from dying so that you can do all of those other tests.... we're talking about 15 minute intervals here. O2, IV, NTG, morphine, move forward.

If they came via EMS, EMS already did this. (Don't forget the aspirin!) And OP didn't mention what time frame. The rest of the posters covered MONA, I was simply going to the next step - Can't treat without the cause.

Eta - it isn't clear whether this is inpatient or someone in the ED. Its in the cardiac nursing/CCU forum. Maybe OP will come back? Hit and run threads suck.

Fish4jibs · May 16, 2016

Give morphine and antiemetic to alleviate pain and anxiety. Check electrolytes, troponin, Magnesium level and current meds. Patient doesn't need pacing at the moment unless he becomes hemodynamically unstable with low BP or pre-syncope.

nursej22, MSN, RN · May 16, 2016

If there are no contraindications, IV metoprolol might be given, to suppress the PVCs, and lower the bp. Still, I would want the labs and history, and a more thorough analysis of the 12 lead, especially looking for any evidence of ST changes.

kaylee. · May 17, 2016

Just a thought, this patient is already unstable, given arrhythmia and cp with the blood pressure. First bp needs to be lowered rapidly, as this could be hypertensive emergency, by 25% in the first 15 minutes. This is the most emergent thing happening...

Pheebz777, BSN, RN · May 19, 2016

STAT cardiac protocol, MONA, EKG, labs, O2 right, cardiac monitor with pacer pads initially

How old is this patient? What were the circumstances/history prior to presenting into the E.R.?