Right Ventricular Infarct--thing I thought I knew...

jmgrn65, RN · Sep 1, 2005

I think you are right, maybe there is something missing? Is her Na increased? Have you tried simply asking the docs why not, ask them to help you understand that way they won't get offended. cause we sure don't want to hurt thier ego's :}

Editorial Team / Admin · Sep 1, 2005

In patients with hypotension and right ventricular infarct, the hemodynamics may improve with volume expansion to augment cardiac output and RV preload. But, was there a LV involvement.......???????????

Initially with RV infarction , you infuse a bolus of fluid to improve the hypotension, but, if the B/P is not corrected after 1 or 2 bolus', hemodynamic monitoring with pulmonary artery catheterization should be considered. Rationale: Further infusions may produce pulmonary congestion......

Her problem is further complicated by renal failure and thereby would go to an inotrope earlier with this patient.......

hrtprncss · Sep 1, 2005

why not do more diagnostic workup before deciding wether to go on the fluid an or vasopressor route, to guide a definitive plan of care.

candyndel · Sep 7, 2005

what do/did her right and left ECGs look like??

papawjohn · Sep 7, 2005

Hey Y'all

Thanx for the replies. Some answers to questions that have accumulated.

She came in with normal BUN/Creatinine. After 3 days of our 'care' her BUN was up to 30 and climbing, urine was 10-20cc/hr.

Actually the Na on morning labs was running low-ish 133-130. (So I was fairly sure I was doing the right thing in convincing the Primary Doc's young partner to let me give the liter of NSS that one night.)

The EKGs were subtle because of prior infarct. I (blush) couldn't see the classic segment elevation in II, III and F. It was the Cardiologist who actually called it an Inferior. I could see infarction in the chest leads over the R side--but the elevation was only a few mm and as I said was complicated by prior damage.

On the day of admission, an Echo showed 40% EF. It also showed 'significant Mitral Regurge'--which made me kinda uncertain about fluid loading her. (Self-doubt is not a bad thing in our line of work--it makes you cautious.)

She never had the classic Vagal-stimulation that I associate w/ InferiorMI. Had no Brady arrhythmias, block, nausea.

I think (I hate when I draw this kind of conclusion--esp cause this Cardiologist is usually on my "good Doc" list) that when she refused CathLab intervention, that she p***ed off the Doc. Added to that, at the NursingHome she was DNR. Further--her son in a fairly distant city (150miles) was POA and they had a poor relationship ("he never comes to see me.") The result was the Cardiology folks washed their hands and didn't want to treat her.

(Related topic--old charts contained references to "BiPolar illness". As I said, she was on no psych meds at NursingHome and never acted 'crazy'--unless it's 'crazy' to refuse CathLab & intervention.)

She died.

Hating this part of the job..."what could I have done...."

Papaw John

Editorial Team / Admin · Sep 7, 2005

Nothing, John. You could not make the patient do the right thing and neither could the physicians.

Unfortunately, this is what happens at the end of life. And, it sounds as if she was ready to die.

You did all you could do. :balloons:

papawjohn · Sep 8, 2005

Hey Siri

Thanx for the kind words. Inevitably, our Pts die--we can only borrow time for them. Hopefully, its a long time--

Still, my goal is to go 'undefeated' by the grim reaper.

Papaw John

Editorial Team / Admin · Sep 8, 2005

Hey Siri
Thanx for the kind words. Inevitably, our Pts die--we can only borrow time for them. Hopefully, its a long time--
Still, my goal is to go 'undefeated' by the grim reaper.
Papaw John

Ah, yes........'fraid you will fall short of your goal. The reaper will gather his quota no matter what.

And, unless you are planning on being raptured, 'fraid you will be going with the reaper one day, too. :)

Surgical Hrt RN · Sep 8, 2005

In patients with hypotension and right ventricular infarct, the hemodynamics may improve with volume expansion to augment cardiac output and RV preload. But, was there a LV involvement.......???????????
Initially with RV infarction , you infuse a bolus of fluid to improve the hypotension, but, if the B/P is not corrected after 1 or 2 bolus', hemodynamic monitoring with pulmonary artery catheterization should be considered. Rationale: Further infusions may produce pulmonary congestion......
Her problem is further complicated by renal failure and thereby would go to an inotrope earlier with this patient.......

Siri,

I agree with your assessment 100%. An inotrope would have worked wonders for this patient. A little Dopamine or Dobutamine would have gone a long way. RV infarcts always need volume and inotropes, not to mention a good ole' fashioned swan!

Editorial Team / Admin · Sep 8, 2005

Siri,
I agree with your assessment 100%. An inotrope would have worked wonders for this patient. A little Dopamine or Dobutamine would have gone a long way. RV infarcts always need volume and inotropes, not to mention a good ole' fashioned swan!

:balloons: Thank you, Surgical Hrt RN :balloons: ,

Probably would not have made a difference in this case, however. As you see, the patient refused any life-saving measures and subsequently died.

SEOBowhntr · Sep 8, 2005

John,

One thing to remember in many RV infarcts is that the Proximal RCA is the culprit, and the vagal thing is often times related to a loss of feed to the SA node. That being said, if the RV infarct is a result of a PDA solely or a more distal RCA occlusion, you may keep SA Node feed, and lack the Brady-arrhythmias, however in ALL RV infarcts you will have the hypotension.

Don't feel bad about this patient, she got something many of us will not get the dignity to do, she got to die with a little honor and dignity without someone coming in and over-riding her wishes. She was blessed to have a nurse care for her who cared as much as yourself, but she felt it was her time and got to settle this one on her terms. Keep your head up, you sound like you did a good job, but only so much can be done with a patient who doesn't really want drastic measure performed. Even with the best of care, many RV infarcts will die, that's just the beast of cardiac care that often times we have no control over. One of my best saves was on an open heart patient who shut down his RCA graft and even with emergent PTCA and a balloon pump for nearly a week, he very nearly died, and this was treated almost immediately!!!

Doug