Question on reacting to tachycardic afib

[DatMurse]

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.

[RescueNinjaKy]

Just wanted to say that this is the type of all nurses posts that I really love to read, when nurses collaborate to further education.

Not gonna lie, was getting tired of all the less than informative posts out there lately

[lazz1]

I think it is quite alright to withhold a medication such as a beta blocker if the heart rate is in the fifty's because I would be cautious in not wanting to cause this patient to brady down further (since this patient already did that before to the 30s). This patient needs a pacemaker. She has tachy/brady syndrome. I would hold the med if her heart rate was that low and get parameters. A good cardiologist would write parameters down at the time of ordering the medication. Most do not, so I would use good judgement and not give the med until I know what parameters the doctor wants.

[michlynn, BSN, RN]

This topic of holding medications, parameters or no parameters seems to be a pretty popular topic. I myself held a dose of lopressor the other evening because it was given in the morning and my pt became bradycardic with a junctional rhythm in the 30's and I was not about to have that happen again on night shift. There were no parameters but as nurses we are the last line of defense against a foreseeable and unreasonable risk of harm or death to a patient. Meaning, if I don't feel it's safe for my pt to have that medication then I'm not going to administer it, of course I'm going to inform the doctor that I don't plan on giving it but it's in my best judgement what is ultimately best for the pt. And I would never leave a pt with a HR sustained in the 140's, if this was going on for more than a couple hours the doc would be paged and I would expect a cardizem gtt (with boluses under our protocol) to be started and an anticoag, and if that didn't touch the HR the doc would be called again.

[OhioCCRN, MSN, NP]

My 2 cents:

I absolutely hold medications and THEN inform the provider. As a nurse, you are an educated individual who should understand medication implications/side effects and know when it is appropriate to withhold the medication for therapeutic purposes, which is practicing nursing and not medicine w/o a license.

re: the HR, just imagine if your heart was beating at 150 for a couple of days, you would be completely pooped. and yes, HF would be waiting to happen. that is why there is concern for the fact that this was not dealt with. To the OP, if something happens to the patient and you are called for a deposition, "i could not read the MD note " is not a valid excuse.

Do you have a rapid response at your facility? I would have called it and gotten the patient transferred to the appropriate level of care (ICU) because Afibb WITH RVR is a medical emergency at my hospital and EVERYTHING is done to bring down that rate before the heart gives up.

[ATLIEN]

I don't like how you are assuming the patient was "admitted for a dumb reason" then yet again, assuming, just chilling out in the 150s afib rvr is okay because it's "asymptomatic" according to you. I guess they have to totally tank before you think it's a big deal. Rather complacent for a new nurse. No offense just reading this is making me a bit worried. Your floor/you obviously weren't qualified to manage the care of this patient. I don't mean that as a jab, but as a real statement. Also where I used to work at if I didn't like the response I was receiving from the noc doc I would call the damn house sup, get the ball rolling... you got to be a take action sort of person, don't just trust everything someone tells you.. think hard, ask your coworkers and really think. Maybe you need a really good resource person to help you. Either way just remember you are dealing with someone's life...this situation you didn't handle correctly. Next time you'll remember. God speed

[DatMurse]

I don't like how you are assuming the patient was "admitted for a dumb reason" then yet again, assuming, just chilling out in the 150s afib rvr is okay because it's "asymptomatic" according to you. I guess they have to totally tank before you think it's a big deal. Rather complacent for a new nurse. No offense just reading this is making me a bit worried. Your floor/you obviously weren't qualified to manage the care of this patient. I don't mean that as a jab, but as a real statement. Also where I used to work at if I didn't like the response I was receiving from the noc doc I would call the damn house sup, get the ball rolling... you got to be a take action sort of person, don't just trust everything someone tells you.. think hard, ask your coworkers and really think. Maybe you need a really good resource person to help you. Either way just remember you are dealing with someone's life...this situation you didn't handle correctly. Next time you'll remember. God speed

You are bumping an old thread.

Did you even read the thread or just come in here to put your 2 cents into an old thread without reading through all the comments of other nurses?

On top of that, the fact that I acknowledged my mistakes.

[ATLIEN]

I said what I believed. So yeah there's my 2 cents. Do with it what you may. Respectfully, I do not engage in arguing on the Internet either. Last response was 1 month ago. That's the only date I looked at. Sorry to have offended you but you posted what you posted and I responded with what I thought. Have a great day! Mod close thread? Thanks!

[Esme12, ASN, BSN, RN]

I think we need to remember that we all have made errors in judgement while we are learning. The OP did realize what he/she can do in the future to best handle this type of situation. I think we as a profession need to be supportive or each other and helo each other grow and learn.

[canned_bread]

It is not an emergency. In fact - a lot of people have AF and don't know about it! It's only scary to untrained eyes really. It's a chronic health issue, and it takes a while before heart failure etc starts becomnig an issue, or stroke starts becomnig a risk. But the patient was probably on aspirin or something anyway.

So basically, I think she was being pushy and dramatic.

[RNDude2012]

It is not an emergency. In fact - a lot of people have AF and don't know about it! It's only scary to untrained eyes really. It's a chronic health issue, and it takes a while before heart failure etc starts becomnig an issue, or stroke starts becomnig a risk. But the patient was probably on aspirin or something anyway.

So basically, I think she was being pushy and dramatic.

This.

Everything is dependent upon the patient's history and what got them admitted in the first place. My main concern is... was the patient on coumadin with a therapeutic INR, or a heparin gtt with a therapeutic ptt in order to prevent a CVA/PE ? The patient was obviously on dilt, which means that this was more than likely a chronic thing, so I'm just assuming that the patient had some kind of anticoagulant ordered. I would be more worried if this was new onset a-fib, and the patient became symptomatic. If the patient had chronic a-fib, was asymptomatic, had okay pressures, and was on a home regimen of coumadin (or something similar), I really wouldn't be worried unless the patient became symptomatic (this is assuming the primary MD and/or cardiology was aware and multiple things had been tried). I've seen this with many chronic a-fib (sometimes even with just paroxysmal a-fib) patients on multiple floors in multiple hospitals working agency. Obviously this can't sustain for days, but if the risk of developing a clot was nil, I personally wouldn't be worried, but I would go ahead and consult with the charge and let the MD know just to CYA. If your coworkers are worried, it's best just entertain their thoughts in order to avoid a bad reputation.

[kaylee.]

with a HR sustained in the 140's, if this was going on for more than a couple hours the doc would be paged and I would expect a cardizem gtt (with boluses under our protocol) to be started

This is an old thread, but oh well...You have to look at the whole picture with this patient, which came out over several posts by the OP. But the post right before the one I am quoting hit the nail on the head: tachy-brady syndrome. Its a type of sick sinus syndrome which causes the symptoms the pt had, which were dizziness/syncope, and the patient goes in and out of rapid afib or other rapid rhythm and then bradys down, or has sinus pauses/arrests. The cardizem didn't "cause" the brady, but can trigger it in these pts and should be d/c'd...this is why the doc is considering a pacemaker, because its the standard of care for this condition.

Nonetheless RVR sustaining 140s would concern me too. Which is why I think it was mentioned they put him on amio and it helped. I would have called and not waited till the am. While cardizem was definitely out, there are still some options instead of letting them sustain for that long...