Upset Over Patient Who Crashed

Updated | Posted

I’ve been on FMLA for a while and last night was my first night back on my med/surge/tele floor. I got an 87 yo old male admission mid shift who presented to the ED with falls, AMS, and abdominal pain. ED worked him up with a head CT, CXR, CT abdomen - everything negative for anything acute, no bleeding on CT. Literally had perfect labs and no UTI, negative Trop. When I got him, he was fine and then for about an hour and then he said his chest hurt. We drew a stat trop and stat EKG, all were normal except a slight bump in his QTC when compared to the ED EKG; however, it remained under 500. His pain quickly subsided and he fell asleep. During rounds every 2 hours, he was fine and states he felt better. Trops were repeated 6 hours later and it was WNL. On tele patient was NSR with occ PVCs. No magnesium level was ordered and I’m kicking myself for not ordering it myself since he was having PVCs.

Morning shift care onboard and I gave a bedside report to the day nurse. The patient was chipper, joking, laughing and looked great. Ten minutes later, tele called and said he was on SVT - sure enough, he was.

A code was called, and I got ripped a new one by the ICU nurse for giving him Lovenox last night, I told her his CT was fine in the ED so I saw no reason to hold it. The patient takes no home meds, and his labs were fine, why would I hold it?  The code team called a CODE stroke and he went to head CT - again, nothing acute  on there and no bleed. During the code stroke, the patient was thrashing his arms around and acting incoherent, not able to understand commands because he was so altered in mentation. I guess the we’re going to scan his neck, but I do not know the outcome since my shift was long over and I was told to go home of my work was done. A CNA text me thar he went to ICU but she doesn’t know what they found. 

I am not going back to work for a week, and I will float so I probably won’t ever find out. I do not know any of the nurses well enough to ask what his outcome was. I am hoping he had a good outcome, I hope he went to the ICU for TPA and will bounce back, do you think that’s a possibility? Wouldn’t the CT show  a clot though? I doubt if it was a MI because his 3rd trop was drawn 15 minutes before this happened and it was fine. 

Wedgepressure, ADN, EMT-B

Specializes in CCL RCIS. Has 3 years experience.

Honestly it sounds like a pretty random case with no definitive answer.  I wouldn't lose sleep over it.  You didn't do anything wrong and checking a mag level for infrequent PVCs is fine, but 2g mag IV is not fixing his problem imo.  This may sound bad, but old people die even if you do everything you can to save them.  By 87 that's pretty much a wrap, everyday is a gift and could be your last.  

6 minutes ago, Wedgepressure said:

Honestly it sounds like a pretty random case with no definitive answer.  I wouldn't lose sleep over it.  You didn't do anything wrong and checking a mag level for infrequent PVCs is fine, but 2g mag IV is not fixing his problem imo.  This may sound bad, but old people die even if you do everything you can to save them.  By 87 that's pretty much a wrap, everyday is a gift and could be your last.  

Thank you so much. In my mind, I did do everything but I am kicking myself for not asking for morphine, nitro or putting him on 02 during his CP episode (Mona). I was running around like crazy and when I saw that his EKG was normal and Trops fine, I let it go. I gave him the Lovenox and Tylenol, he was better afterwards. I would have called the doctor and asked for MONA orders, but I could barely understand him when I called to get admission orders - he had a very strong and different accent than mine, and his phone connection was bad. I also had to page twice for orders because he didn’t call after my first page. I did the bare minimum to get the patient thru it because I had too much going on than to keep paying him. I wish I would have listened to my gut and gotten MONA orders and a Mag, but at the same time, I’m not the doctor, why didn’t he open up his computer and put orders in himself, ya know? I hope the patient is good, getting TPA, and not in a “vegetable” state now. I know he’s still in ICU, but I don’t know his condition.

amoLucia

Specializes in retired LTC.

Things can be very iffy quickly with the elderly.

What are MONA orders??? It's been some time for me.

 

 

9 minutes ago, amoLucia said:

Things can be very iffy quickly with the elderly.

What are MONA orders??? It's been some time for me.

 

 

Mona is the acronym for Morphine, oxygen, nitro sublingual, aspirin. Mona should be given for any Patient with chest pain. 

amoLucia

Specializes in retired LTC.

Thank you.   In LTC, there's really no backup, so I just did the oxy & NTG, routinely. But I'd be readying the pt for transfer out of the NH FAST!! So 911 could do their protocol as soon as they got to us.

My IMMEDIATE gold-standard question was to ask 'have you ever had this pain before?' And then to ask, 'what did you do for it?'. If they told me 'yes', and 'they used the little pill under the tongue', I MOVED EVEN QUICKER.

By then, I'd usually have the PMP on line, so aspirin would prob be ordered but always check for allergy & if on standard ASA dose already.

The thing that scared me was if I GAVE a NTG and it WORKED!

Just to say to you to be positive, was a fall current? Even if tests were OK, he could now just be FALL-hurting. Think positively.

Come back to keep us updated. +++

PMFB-RN, BSN, RN

Specializes in burn ICU, SICU, ER, Traum Rapid Response. Has 16 years experience.

8 hours ago, raindrop said:

I’ve been on FMLA for a while and last night was my first night back on my med/surge/tele floor. I got an 87 yo old male admission mid shift who presented to the ED with falls, AMS, and abdominal pain. ED worked him up with a head CT, CXR, CT abdomen - everything negative for anything acute, no bleeding on CT. Literally had perfect labs and no UTI, negative Trop. When I got him, he was fine and then for about an hour and then he said his chest hurt. We drew a stat trop and stat EKG, all were normal except a slight bump in his QTC when compared to the ED EKG; however, it remained under 500. His pain quickly subsided and he fell asleep. During rounds every 2 hours, he was fine and states he felt better. Trops were repeated 6 hours later and it was WNL. On tele patient was NSR with occ PVCs. No magnesium level was ordered and I’m kicking myself for not ordering it myself since he was having PVCs.

Morning shift care onboard and I gave a bedside report to the day nurse. The patient was chipper, joking, laughing and looked great. Ten minutes later, tele called and said he was on SVT - sure enough, he was.

A code was called, and I got ripped a new one by the ICU nurse for giving him Lovenox last night, I told her his CT was fine in the ED so I saw no reason to hold it. The patient takes no home meds, and his labs were fine, why would I hold it?  The code team called a CODE stroke and he went to head CT - again, nothing acute  on there and no bleed. During the code stroke, the patient was thrashing his arms around and acting incoherent, not able to understand commands because he was so altered in mentation. I guess the we’re going to scan his neck, but I do not know the outcome since my shift was long over and I was told to go home of my work was done. A CNA text me thar he went to ICU but she doesn’t know what they found. 

I am not going back to work for a week, and I will float so I probably won’t ever find out. I do not know any of the nurses well enough to ask what his outcome was. I am hoping he had a good outcome, I hope he went to the ICU for TPA and will bounce back, do you think that’s a possibility? Wouldn’t the CT show  a clot though? I doubt if it was a MI because his 3rd trop was drawn 15 minutes before this happened and it was fine. 

 

 

 

It was irresponsible for the providers to not check his mag levels. And you should have checked them when you noticed he was having PVCs.

   Head CT will not show an occlusive stroke. We do them to rule out hemorrhagic strokes before giving TPA to treat occlusive stroke.

    Based on what you have related I see no reason why you should have held the Lovenox and the ICU RN had no basis to "rip you a new one". Don't let them do that to you. 

   Except for missing the Mag, sounds like you took good care of him and have no reason to feel bad. 

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

Remember that as a nurse your role is to help identify and intervene where there are reasonably identifiable and actionable data or symptoms, it's not to make the impossible possible.

First, MONA is no longer a thing, no patient should be given MONA even if you have evidence of an Acute Coronary Syndrome, much less for chest pain alone.

It's always been a bit frustrating that a magnesium level typically isn't a standard part of a basic metabolic panel, but typically with a normal potassium there is little benefit to treating a magnesium level unless it is significantly low.  In most patients, the main benefit of a normal magnesium level is that it helps maintain a normal potassium level.

Intermittent single PVC's, particularly in an 87 year old, is not particularly unusual or a clear indicator of impending unstable rhythm.

I have no idea why the ICU nurse berated you for giving the lovenox, except that some ICU nurses are kind of a-holes when talking to non-ICU nurses.

"SVT" is a pretty broad term, it includes a wide variety of rhythms, so it's hard to say how that played into the situation.  

Regardless though there's nothing you appeared to do wrong, please don't beat yourself up over the fact that sometimes otherwise unexpected medical events occur in 87 year olds.  

PMFB-RN, BSN, RN

Specializes in burn ICU, SICU, ER, Traum Rapid Response. Has 16 years experience.

5 hours ago, raindrop said:

Mona is the acronym for Morphine, oxygen, nitro sublingual, aspirin. Mona should be given for any Patient with chest pain. 

This made me feel like I just stepped into 1995.

Edited by PMFB-RN
spelling

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

I work outpatient so fill me in.  What's wrong with MONA?  If a patient is having signs of a heart attack in our clinic, while waiting for the EMTs to arrive, we do give aspirin and maybe oxygen (not always).  We don't have morphine sitting around but we do have nitroglycerin; I'm not sure if it is used or not. 

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

2 hours ago, CommunityRNBSN said:

I work outpatient so fill me in.  What's wrong with MONA?  If a patient is having signs of a heart attack in our clinic, while waiting for the EMTs to arrive, we do give aspirin and maybe oxygen (not always).  We don't have morphine sitting around but we do have nitroglycerin; I'm not sure if it is used or not. 

MONA was retired by the AHA from BLS and ACLS algorithms a few years ago.  Primarily the reflexive use of these medications and oxygen with suspected Acute Coronary Syndrome (ACS)

Aspirin is still indicated for suspected ACS, so long as there are no contraindications. 

But there's been evidence that administering oxygen without evident hypoxia may do more harm than good. 

If ACS is suspected but it can't be ruled out that there is an infarct impairing the right ventricle then nitroglycerin should not be used, giving nitro to a patient having an RV MI can be fatal.  

To a lesser degree, the risk of giving morphine is also true when an RV MI can't be ruled out, but also it has the potential to cause more problems, mainly due to N/V, than it offers in benefit in terms of coronary artery dilation.

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 3 years experience.

12 hours ago, MunoRN said:

MONA was retired by the AHA from BLS and ACLS algorithms a few years ago.  Primarily the reflexive use of these medications and oxygen with suspected Acute Coronary Syndrome (ACS)

Aspirin is still indicated for suspected ACS, so long as there are no contraindications. 

But there's been evidence that administering oxygen without evident hypoxia may do more harm than good. 

If ACS is suspected but it can't be ruled out that there is an infarct impairing the right ventricle then nitroglycerin should not be used, giving nitro to a patient having an RV MI can be fatal.  

To a lesser degree, the risk of giving morphine is also true when an RV MI can't be ruled out, but also it has the potential to cause more problems, mainly due to N/V, than it offers in benefit in terms of coronary artery dilation.

Thanks!