How woud you treat this patient...

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How would you treat this patient:

C/o chest pain and is very anxious.

His 12 lead shows a heart rate of 60, but it is bigeminy and his palpable pulse rate is 30.

His BP is 220/110.

Specializes in Nurse Anesthesiology.

Besides rate what does 12 lead show? Ischemia?... C/O CP with arrhythmia deserves further workup. Send off lytes, cardiac enzymes, put on 100% O2, give sublingual nitro or start on NTG gtt, morphine, ASA as long as no contraindications. This is pretty straight forward... not sure what would be confusing?

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Specializes in ICU, CVICU, E.R..
If there are no contraindications, IV metoprolol might be given, to suppress the PVCs, and lower the bp.

Not with a HR of 30. Tridil drip would be best to control the chest pain and lower BP.

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Why would you give BB? His HR is already compromised. Hypertension might be due to anxiety and compensatory to his bradycardia.

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Specializes in Cath/EP lab, CCU, Cardiac stepdown.

I'm pretty much new to ccu, but what about an amio bolus and nitro drip. Then correct whatever lytes as well.

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Specializes in Public Health, TB.
Why would you give BB? His HR is already compromised. Hypertension might be due to anxiety and compensatory to his bradycardia.

In the original post, the patient was in sinus rhythm with bigeminy at 60, but the palpable pulse was only 30. Only every other beat was perfusing. PVCs interrupted ventricular filling, so when the sinus beat occurs, there is not enough blood to push and create a pulse. A beta blocker will suppress the PVCs, and even if it slightly lowers the sinus rate, a pulse rate of 50 is more desirable than one of 30.

Also, a beta blocker such as metoprolol with relax the myocardium and lower the blood pressure, and reducing the left ventricular strain with decrease pain, and lower the bp even more.

And of course, a 12 lead, labs and a focused history is necessary.

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Specializes in Cath/EP lab, CCU, Cardiac stepdown.
In the original post, the patient was in sinus rhythm with bigeminy at 60, but the palpable pulse was only 30. Only every other beat was perfusing. PVCs interrupted ventricular filling, so when the sinus beat occurs, there is not enough blood to push and create a pulse. A beta blocker will suppress the PVCs, and even if it slightly lowers the sinus rate, a pulse rate of 50 is more desirable than one of 30.

Also, a beta blocker such as metoprolol with relax the myocardium and lower the blood pressure, and reducing the left ventricular strain with decrease pain, and lower the bp even more.

And of course, a 12 lead, labs and a focused history is necessary.

I feel like ivp of metoprolol will have effects on the blood pressure and heart rate but not necessarily the pvc right away. Some people just don't like to respond. This is all purely speculation on my part tho.

What about hydralyzine to lower the bp right away and then ventricular antiarthymics or something like amio that works on both atrial and ventricular

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Specializes in Public Health, TB.

I've seen IV metoprolol work pretty quickly, your mileage may vary. I would want potassium and magnesium levels and correction, prior to giving amio, as well as healthy history and a 12 lead.

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I'm the OP. So, after much chin scratching, I think what the patient needs is a transvenous pacer. I originally said external pacing, but I don't think that would work because the pain would just add to the patient's stress and anxiety.

The problem with the patient, as I see it, is that in order to compensate for the reduced cardiac ouput from the low heart rate, his systemic vascular resistance is maximally clamped down to sustain a BP. His tired old heart is having to pump against this massive afterload, which could explain the bigeminy and chest pain.

So, if you place a transvenous pacer and bring him back up to a normal BP, the cardiac output will increase, and then hopefully the SVR will relax, and the workload on his heart will be much reduced.

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Specializes in Research & Critical Care.

There's not enough information to even start thinking about medications.

Age, prior history, and what was happening at onset quickly come to mind. A ten y/o boy with chest pain from a respiratory infection is going to be treated differently than a 76 y/o with a known history of CAD and stent placement. Is this a ESRD patient with critical electrolytes? Maybe this is a construction worker that just got shot in the chest with a nail gun.

Bradycardia can cause hypertension, but hypertension can cause bradycardia. And yes, beta blockers can suppress PVC's, but only if the PVC is related to the adrenergic system. These PVC's could be a calcium channel abnormality and then you'll really need to start pacing.

Assess first!

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Specializes in Family Nurse Practitioner.

Hydralazine and lidocaine?

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Why lidocaine? Unless pt is having VT storm and in my hospital that is not even the first drug of choice.

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Specializes in Cardiac.

For a Cards floor....I'd follow the Cards CP protocol...nitro...Labs...ekg...obviously get the MD involved...if cp not going away anticipate nitro gtt...if pin continues or pt deteriorates or EKGs changes prep for stat Cath. The CP is the biggie. That needs to be controlled. Bigemeny...I'd watch and be sure lytes ok so pt won't go into a lethal rhythm. I could go on but that's the history.

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