Metoprolol IVP rate

[kmoonshine, RN]

Quick question:

How fast can one push metoprolol 5mg x 3 for acute MI that will be going up to cath lab?

Some of the literature I read states 5mg over 5min, some says 5mg over 2-3 minutes, some literature states rapid push with 2 minutes between doses.

I need a good book/PDA program for emergency meds. The "rules" often seem different for many meds used in the ED. Any recommendations?

Tonight I had a pt having an acute MI and nobody could get a peripheral IV in. The MD placed an EJ. Normally I like to have 2-3 lines to hook up all the meds for cath lab patients, but the one EJ is all we got . IV med orders included heparin drip, heparin bolus, metoprolol, nitro drip, reopro; it's not possible to get these all in through one line since time is muscle....

[JBudd, MSN]

In the ER, especially with an active MI, I'd go with the ACLS standards. That's the 5 over 5 isn't it?

Several of my coworkers have the little flip book of ACLS algorythms and drug sheets, and they seem to like them.

When someone is in full cardiac arrest, the 2 minute push rule seems a little off doesn't it? ACLS changes on us too though, they no longer seem to think any drug down the ET is going to be useful, where we used to simply double or triple the dose.

[ERRNTraveler, RN]

For acute MI in the ER: 5mg IVP x 3 doses- can give each dose over 2 min, with 5 min. between doses. Hold for HR

[ERRNTraveler, RN]

JBudd said:

When someone is in full cardiac arrest, the 2 minute push rule seems a little off doesn't it?

Lopressor isn't given for full cardiac arrest....

[avery]

ERRNTraveler said:

For acute MI in the ER: 5mg IVP x 3 doses- can give each dose over 2 min, with 5 min. between doses. Hold for HR

This is how we give it in the cardiac ICU Avery

[DutchgirlRN, ASN, RN]

In radiology pre CTA we give 15 mg over 5 minutes. Wait 15 minutes and give another 35mg over 7 minutes. DC for HR

I realize this is not talking about an MI but if this protocol is safe for radiology I don't know why it wouldn't be safe for an MI.

[walk6miles]

Dutchgirl

Are you referring to a catscan of artery (CTA) when you say you give 15 then 35 mg... I am not familiar with the procedure you refer to, please clarify.. thanks,Walk

[AnnieOaklyRN, BSN, RN, EMT-P]

Hi,

I work in the feild as a medic and here is my take on Lopressor:

If it is an acute ANTERIOR, LATERAL, or SEPTAL (or all three is some patients) then it is generally safe to push Lopressor over 2 minutes as these pateints have an increased sympathetic tone and it doesnt have as much of an effect as it would on patients with other types of ACS. Obviously, however one would use caution if the patient was on the cusp of hypotension or had a HR in the 70s or so... but again most patients with this type of MI are tachycardic with mild-moderate hypertension unless they are in cardiogenic shock and then you wouldnt give it anyway.

In Acute INFERIOR, POSTERIOR, ESPECIALLY WITH Right sided infarct you would give lopressor over at least 5 minutes per a 5 mg dose if you are to give it at all. It is important to use caution with lopressor in these types of MIs as there is an increase in parasympathetic tone because of irritation to the phrenic nerve. Most patient with inferior MI, some with posterior MI (because the inferior wall is usually involved as well) will be bradycardic anyway and will not be able to receive lopressor. Patients with Right sided MI should not receive lopressor, nitrates, or morphine since you could kill them, even if their BP is >90 systolic. Fluid fluid fluid for those Right sided MIs which also involve the inferior wall as well a majority of the time.

So anyway.. my point is, that the rate of administration of Lopressor and any other medication should be based on the patients condition and VS and not soley on what the lititure states it should be.

Ok getting off my soap box now.

Swtooth

[jmgrn65, RN]

If you push it too fast you will not have hr and or bp for long. I would not push less than 2min and I think that is pushing it a little. (pardon the pun).

I am curious what literature says to push it fast? Just my 2 cents, been there done that.

[DutchgirlRN, ASN, RN]

walk6miles said:

Dutchgirl

Are you referring to a catscan of artery (CTA) when you say you give 15 then 35 mg... I am not familiar with the procedure you refer to, please clarify.. thanks,Walk

CT Arteriogram

HR needs to be around 60 bpm, hence Lopressor IVP

[RNFPC]

SWtooth,

I'm going to have to respectfully disagree with your comments regarding RVI's.

Metoprolol may be used in RVI's... they are preload dependent for the cardiac output, however, metoprolol can be used cautiously.

Addtionally, both nitrates and morphine can be used. Nitrates need to be used with caution, but they can be used and they can be effective in dilating coronary arteries (NB - don't use sublingual NTG - 400mcg is just too much, use a NTG drip). They just need to be given with fluid. As to morphine, there's two things to keep in mind: 1) morphine causes a histamine release which will cause mild hypotension (again have fluid going) and 2) most of the reduction in BP that we see with morphine is due to decreasing pain and decreased catecholamine release (all analgesics will do this). When it comes to pain control with AMI's, I personally prefer to use fentanyl and avoid the histamine release.

Also, most of the inferior wall MI's I have dealt with have not been bradycardic and most have not been hypotensive and most have tolerated IV nitrates well.

Just my 0.02...

[kmoonshine, RN]

Thanks for all the replies. I was working with an ED doc yesterday who was furious because I was pushing the metoprolol "too slow" and had not gotten a nitro drip started yet (again, only one working IV; when I started pushing the metoprolol, I had no idea that the other RN's would be unsuccessful with getting a peripheral IV). I had the nitro ready to go once the metoprolol was in. She had taken 4 nitro at home, and her BP=150/84, HR=76. She also had an internal pacer.

Another RN who was taking over my room assignment for the next shift came up to me and said "you could have gave the metoprolol faster than over 5 minutes, you know". I told her that I didn't want to put the patient into asystole by pushing it too fast. She seemed confident that you can give it rapid push. This is coming from an RN who I once saw give phenergan IVP through a 24g IV in the hand (this patient had ESRD and was on dialysis, and a 24g was all we were able to get) ...

Now I feel better for monitoring the BP while giving the metoprolol slowly. BTW, cath lab was not ready for the patient yet, so it's not like I was holding things up. The MD knew we only had one EJ and said he wanted the heparin bolus, metoprolol, reopro (which we had to order from pharmacy) and nitro going in the one line, while other RN's attempted a second line for the heparin drip.

This MD can be a real bully at times and I shouldn't have allowed him to get under my skin. This patient came in ambulatory and was brought right back to my room where I got the EKG within 5 minutes (and shown to MD); cath lab was called immediately and the cardiologist was in the ED 40 minutes later. I thought we did pretty good, considering no one could get in an IV for 20 minutes!

Next time I'll give the metoprolol to the MD and say "go ahead, if you want it fast, then you can push it".

The cardiac cath went well, no blockage was found .