Question on reacting to tachycardic afib

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Specializes in Hematology/Oncology.

So I have a question for you cardiac nurses.

-Quick rundown. patient used to be on 120mg of cardizem ER.

-patient was running brady and possible syncope on admittance

-doctor dc cardizem.

-pt is running afib/aflutter in the 130s-150s over the past few days, asymptomatic.

-I wasnt worried about it and the tele monitor is calling em and harassing me over something that has been unchanged.

-The hospitalist has known about this for the past few days.

-I get a call from their charge nurse asking em if the hospitalist knows about this. The day hospitalist knew about this and I felt that this can wait. She paged the night hospitalist to come over to my floor, the hospitalist wasnt worried, neither were any nurse on my floor.

So did I do the right thing? For something that has been unchanged over the past few days, is it necessary to call the hospitalist if the patient is asymptomatic? Day hospitalist even charted it in his progress notes.

side note: This telemonitor has overstepped her boundaries in the past and trying to get me to give an oncology patient fluids because her admitting diagnosis was for dehydration(The lady was on her last leg and she was changed to a palliative care the next day because of the metastasis of her cancer). She has also told her charge nurse to call me and even at a point told me that her charge nurse recommended me push adenosine on someone that had orthostatic tachycardia.

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Even more concerning to me, is what is the plan for this patient? Even if the patient is asymptomatic, you can't just let them sit there taching away for days and days. What was being done for rate control?

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Specializes in Hematology/Oncology.
Even more concerning to me, is what is the plan for this patient? Even if the patient is asymptomatic, you can't just let them sit there taching away for days and days. What was being done for rate control?

Apparently the cardiologist was coming in the next day to alter cardiac med regiment. no one said anything and I cannot read the doctor's progress notes(illegible). Patient tanked to 30s during days after getting half of normal dose of cardizem. Amiodarone was started last night so I am going to find out what happened.

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I mean this in the kindest way possible, but this is a patient that I would definitely be worried about. Not being able to read the hospitalist's handwriting is no excuse for not knowing what the plan is for this patient. It shouldn't take the monitor tech overstepping to spur you to act. You are the nurse. The buck stops with you. Again, I don't mean to be unkind. I hope you take my feedback in the spirit of improving your practice and doing better in the future.

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Specializes in Hematology/Oncology.
I mean this in the kindest way possible, but this is a patient that I would definitely be worried about. Not being able to read the hospitalist's handwriting is no excuse for not knowing what the plan is for this patient. It shouldn't take the monitor tech overstepping to spur you to act. You are the nurse. The buck stops with you. Again, I don't mean to be unkind. I hope you take my feedback in the spirit of improving your practice and doing better in the future.

I failed to mention am the night nurse. In my defense I am not in communication of the attending and can only follow whatever progress note/report that I can.

The night hospitalist gave her cardizem which they dced that actually caused her to tank to the 30s.

I knew that they were titrating their cardiac meds. I just didnt know the cardiologist was coming in the next day.

I will take your comment into consideration, I hope that I do not come across this again. I know I have alot of learning to do(which is why I am asking about this). I talked with a doctor about me not calling. They said it is not an unexpected change and could have waited until morning to report off to the next nurse to notify the patient's attending hospitalist.

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That rate is far too high as a sustained rate. I would be calling the MD, day or night shift. It can be detrimental to the patient for the heart to be beating that fast for that long. There are other options besides cardizem.

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Specializes in Hematology/Oncology.
There are other options besides cardizem.

I am not experienced/comfortable(with cardiac meds) enough to request specific cardiac medications(other than metoprolol).

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Specializes in ED, Cardiac-step down, tele, med surg.

I'm surprised the cardiologist wasn't consulted on day 1. I would have called the cardiologist on the case about the sustaining A-fib with RVR. It's a dangerous rhythm due to blood clots, plus it is taxing on the heart itself. 130s to 150s is fast, for days? Wow. With that said, you stated that they tried cardizem (a drip I presume) which caused them to drop into the 30s? Then they tried amio?

I had a patient once who's afib with rvr was not responding to drips, and the amio and cardizem was causing significant sinus arrests (as long as 8 seconds). He needed a pacemaker.

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Specializes in Hematology/Oncology.
I'm surprised the cardiologist wasn't consulted on day 1. I would have called the cardiologist on the case about the sustaining A-fib with RVR. It's a dangerous rhythm due to blood clots, plus it is taxing on the heart itself. 130s to 150s is fast, for days? Wow. With that said, you stated that they tried cardizem (a drip I presume) which caused them to drop into the 30s? Then they tried amio?

I had a patient once who's afib with rvr was not responding to drips, and the amio and cardizem was causing significant sinus arrests (as long as 8 seconds). He needed a pacemaker.

The doctor was consulted when she bradied down to 30 on day 1 of admit(she was admitted for a dumb reason) and then is started snowballing from tehre.

Cardiologist agreed to dc cardizem. apparently started rising in the 130s where the hospitalist was aware. I guess the cardiologist came back in 2 days. We had 75mg of metoprolol ordered and 5ml ordered to push IV q6. the metoprolol didnt touch the patient. The patient was on eliquis for the afib.

The cardizem was on oral. I am on a med/onc floor and wanted to ask some more to cardiac nurses. amiodarone stabilized her hr. 400mg bid. I have been with holding the oral metoprolol just because her heart has been in the 50s and that I'd in parameters to hold. They are thinking about a possible pacemaker in a few weeks with a f/u.

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I have been with holding the oral metoprolol just because her heart has been so stable.

Glad that the patient's HR has come down with the Amioderone. You seem to be conscientious w/ a desire to learn and do what's best for your patients. With that said, concerning holding the Metoprolol: have you spoken with the MD and gotten an order to hold it? Or, are there written parameters that the pt. is meeting in order to hold it? You cannot hold it "just because her heart has been so stable". It may be stable in part b/c of the Metoprolol. Holding it without an MD order to hold it is practicing medicine w/o a license.

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Specializes in Hematology/Oncology.
Glad that the patient's HR has come down with the Amioderone. You seem to be conscientious w/ a desire to learn and do what's best for your patients. With that said, concerning holding the Metoprolol: have you spoken with the MD and gotten an order to hold it? Or, are there written parameters that the pt. is meeting in order to hold it? You cannot hold it "just because her heart has been so stable". It may be stable in part b/c of the Metoprolol. Holding it without an MD order to hold it is practicing medicine w/o a license.

Sorry. Meant to say been holding it because he has been in 50s and following parameters

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Sorry. Meant to say been holding it because he has been in 50s and following parameters

Good :-) Sorry if I sounded harsh but I wanted to make sure you knew that.

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