SL Nitro Error...How is this possible?

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Specializes in Emergency.

Hi all,

No, it was not my error, but I got the patient at start of shift.

Ok, here is the situation:

There was a new admit to the unit who came in for CP. Per my charge, he had active 10/10 pain on arrival to the room. The nurse who had him is a floater who sometimes works in our ER as well. Our protocol in the hospital is NTG SL x3 doses max q5 min, with vitals before each tablet. we also do a 12 lead EKG, and call the MD. If 3 NTG don't work, we get further orders. We stop giving NTG if the SBP goes below 90.

Anyway, this nurse actually gave the patient the WHOLE bottle (25 tabs) of NTG! The only way we found out about this is because the Clin II went to help her, and saw the pills in the patients mouth.

When questioned about this, the nurse said she had always done it that way. I have to wonder how many patients she has done this to. Scary!

Anyway, I got this patient, and was all over him since I was expecting his B/P to crash, and was prepared for a transfer to ICU or Stepdown. Amazingly, the lowest his B/P got was 98 systolic. He was a little tachy, but not alarming. I had my CNA checking vitals every 5 minutes, and basically spent the first few hours of my shift in the patients room. Patient was fine, never a problem....how is this possible? BTW, his pain did go away, and he never even got a headache! I know some people never get a change in their B/P with NTG, but I have never seen a pt recieve so much at one time...

Any thoughts?

BTW, I am sure the nurse is in serious trouble for this, she is VERY lucky she didn't kill this guy.

Amy:eek:

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Specializes in Cath Lab/ ICU.

OMG...!:eek:

The real question is, does she give an entire bottle q5x3??? I'm sure she didn't but this is quite reckless behavior that endangers her pts. Wonder what else she has done....

Scary.

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Specializes in adult ICU.

Holy buckets!!!!

The only thing that I can think of is that the NTG was mostly dead. The shelf life of nitroglycerin is only about 6 months, less if the top didn't get screwed back on well so it was exposed to light/moisture. If the bottle had already been opened, I would think that.

1 NTG alone is a big dose (400 mcg). When you consider that when you put people on NTG gtts at 10-20-30 mcg/min, to get 400 mcg x 25 (or however many were left in the bottle) all at once is absolutely insane. It's a good thing it didn't work or the patient would definitely have had to transfer to ICU for some B/P support.

Wow, wow, wow. It's been awhile since I've heard something that bad!

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Specializes in Emergency.

Hi all,

FYI: The patient never had a problem. He was discharged the next day after a negative stress test. I think I am still in shock over this one... Can you imagine if we had never found out and the patient developed symptoms? I get nervous giving just one NTG since I have seen some wierd reactions!

Amy

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