loopingrace

Wow, great feedback! I want to thank everybody that replied. Yes, he initially was in a rapid A-Fib. On arrival his rate was in the 120's but when the MD asked me to given Cardizem his rate was in the low 100's. Dopamine at our institution can be given up to 50 mcg. I believe our ICU does differently; after 30 mcg, they will start Levophed. I'm not sure about his clotting times. I didn't check them myself, but I don't believe the physician mentioned clotting times were significantly abnormal. There was no talk about synchronized cardioversion intially because this patient had a history of CVA, HTN and heart disease, and his baseline EKG rhythm was unknown. The family members were horrible historians and the patient was altered and aphasic.

Hi everyone. I'm a new nurse coming up on one year of experience in a Level II Trauma Center Emergency Department and I need advice. This one patient stumped me. He was crumping the minute paramedics brought into the department. Had a BP 84/52 and a HR 125. He was breathing 40/min and our ER MD decided to intubate. We started giving him IV fluids (NS X 2 liters). He didn't have any signs of CHF- despite the SOB his lung sounds were ok and he had no JVD/ pedal edema. His initial complaint was rapid onset of left sided paralysis. He had a history of left sided weakness from a prior CVA, but this paralysis was new. Anyway, after we started fluids on him, we took him to CT to R/O bleed. When we came back, his blood pressure hovered in the 80's systolic. At this point, his 2nd liter was halfway done. I received an order to give Cardizem 10 mg IVP, to "Stimulate his atrial kick" according to the physician. I guess she was suspecting cardiogenic shock? My question however is "Why dump fluids into somebody if you're suspecting cardiogenic shock?" I advised the MD that the BP was low, she intructed to give it slow IVP and watch his BP, which I did. I slowly gave 5 mg of Cardizem and watched his BP go down to 64, then 54. I held the rest of the medication and notified the MD. She instructed to give more fluids. I ask "Any pressors?" I received an order to start the patient on Dopamine. I start the patient on Dopamine and titrate up. I started at 25 mcg, then titrated up to 50 mcg. This did nothing for his blood pressure and the MD wanted to then give dobutamine. At this point my patient brady'd down into the 40's and the physician stated to cancel dobutamine and start Levophed. While I'm preparing meds, the MD walks into the room and says she doesn't feel pulses and starts CPR. Anyway, we code this guy. Initially he was in a PEA brady at 44. Then after rounds of medications and CPR, back and forth from Vfib to asystole, etc, pacing the guy, defibrillating, etc. The MD pronounces. Not having any ICU experience besides the 13 week internship I had in school, my question is: Which vasopressor is chosen to be used at what time? Rather, which vasopressor is better for what patient? Dopamine, dobutamine, levophed? Are they the same as far as effect on BP/HR? Or are some more for HR vs. BP? By the way, after my patient coded, we saw his labwork where his BNP was 120 and his troponin was negative. CT was negative for bleed. Do you think this guy was a PE? ANY ADVICE/ETC WOULD BE GREATLY APPRECIATED!!

Hi everyone. I'm a new nurse coming up on one year of experience in a Level II Trauma Center Emergency Department and I need advice. This one patient stumped me. He was crumping the minute paramedics brought into the department. Had a BP 84/52 and a HR 125. He was breathing 40/min and our ER MD decided to intubate. We started giving him IV fluids (NS X 2 liters). He didn't have any signs of CHF- despite the SOB his lung sounds were ok and he had no JVD/ pedal edema. His initial complaint was rapid onset of left sided paralysis. He had a history of left sided weakness from a prior CVA, but this paralysis was new. Anyway, after we started fluids on him, we took him to CT to R/O bleed. When we came back, his blood pressure hovered in the 80's systolic. At this point, his 2nd liter was halfway done. I received an order to give Cardizem 10 mg IVP, to "Stimulate his atrial kick" according to the physician. I guess she was suspecting cardiogenic shock? My question however is "Why dump fluids into somebody if you're suspecting cardiogenic shock?" I advised the MD that the BP was low, she intructed to give it slow IVP and watch his BP, which I did. I slowly gave 5 mg of Cardizem and watched his BP go down to 64, then 54. I held the rest of the medication and notified the MD. She instructed to give more fluids. I ask "Any pressors?" I received an order to start the patient on Dopamine. I start the patient on Dopamine and titrate up. I started at 25 mcg, then titrated up to 50 mcg. This did nothing for his blood pressure and the MD wanted to then give dobutamine. At this point my patient brady'd down into the 40's and the physician stated to cancel dobutamine and start Levophed. While I'm preparing meds, the MD walks into the room and says she doesn't feel pulses and starts CPR. Anyway, we code this guy. Initially he was in a PEA brady at 44. Then after rounds of medications and CPR, back and forth from Vfib to asystole, etc, pacing the guy, defibrillating, etc. The MD pronounces. Not having any ICU experience besides the 13 week internship I had in school, my question is: Which vasopressor is chosen to be used at what time? Rather, which vasopressor is better for what patient? Dopamine, dobutamine, levophed? Are they the same as far as effect on BP/HR? Or are some more for HR vs. BP? By the way, after my patient coded, we saw his labwork where his BNP was 120 and his troponin was negative. CT was negative for bleed. Do you think this guy was a PE? ANY ADVICE/ETC WOULD BE GREATLY APPRECIATED!!

Haha I thought this post was hilarious! My thoughts exactly! :)

You did a great job and handled such a hard time both for you and for the family so well. I'm glad you had the support of your co-workers in such a hectic time!

I used to wear a sleeping mask, but that crap does not work for me. It would be uncomfortable sometimes, and would shift around my face, not entirely covering my eyes and such. I got so fed up, then found out about blackout curtains from a co-worker. I recently bought these pair of blackout curtains from overstock.com and they're wonderful! http://www.overstock.com/Home-Garden/Solid-Insulated-Thermal-63-inch-Blackout-Curtains/2946006/product.html I have them on a tension rod on the inside of the window panel right now. A little bit of light does shine through the cracks this way. But even with the cracks, on my day off I tend to sleep in late because it's still so dark in my room! If I wasn't so lazy, I could install a rod to sit over the entire window, and let the curtains fall over the window itself, instead of sitting inside it. This would definitely allow no light to shine through. Great great product. Just an FYI, the "chocolate" color as displayed on the color inset is in actuality a lot lighter once the product arrives at your door. Hope this helps!

Sometimes I feel the same way. I recently graduated in June and have been working since in the emergency room in a busy trauma center in LA. I work night shift and the adjustment to sleeping during the day plus having so much responsibility makes it hard for me to sleep during my days off. Sometimes I cry because my thoughts about my shift are racing, and I'm so frustrated I can't concentrate on sleep. However, I know I must stick through it for another year to get that experience then I can move on to something else. That's the beauty of nursing-- if you're unhappy with one specialty, there are many more you can choose from. I also suggest getting amply amounts of stretching and exercising, peeing when you have to during your shift (I know you're busy, but you have to take care of yourself too, otherwise nobody else to take care of patients!), and tons of water when you work. And also, finding something outside of work that you love. For me, it's my dog, my fiancee, and cooking. Eating too. Hang in there. Know you're not the only one feeling down. Every new nurse goes through something like this, I think.