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.
"MONA was retired by the AHA from BLS and ACLS algorithms a few years ago."
The fact that this message was not conveyed/received appropriately is exactly why those online modules are useless. I feel bad for the newbies taking ACLS for the first time. My in person classes, with actual real people teaching and telling stories, were so valuable.
"MONA was retired by the AHA from BLS and ACLS algorithms a few years ago."
The fact that this message was not conveyed/received appropriately is exactly why those online modules are useless. I feel bad for the newbies taking ACLS for the first time. My in person classes, with actual real people teaching and telling stories, were so valuable.
And I've gotten the impression that the AHA-produced curriculum kind of skims over that, they aren't particularly known for being up-front about when it turns out they didn't have something exactly right.
For reasons that are beyond me, the company that teaches ACLS in my area and/or my organization has refused to switch to online ACLS, even during a pandemic. The full class, even for a refresher is still in-person. But the advantage to that is that we have non-AHA instructors who are quick to point out what the AHA has changed their mind on, which really should be the main focus of any ACLS refresher.
I think like any other group that sets practice expectations, the American Heart Association is deathly afraid of admitting when they got something wrong, which they should really view as they had good information before, but now they have far better information, but they should also recognize that we all assume there is more to know and if a group isn't willing to freely admit that then maybe they shouldn't be in the role they are in.
You did fine. Don’t beat yourself up, people that have to lose sleep over not ordering the right lab test are called doctors. You were working your butt off, and I have a sneaking suspicion this wasn’t your only patient while all this was going on : ) No matter what else was going on, nothing was going to change 87. Next time you can add on a mag, but as the other poster said, I'd be surprised if an 87-year old didn't have some PVCs.
Any time your pt has AMS you should check a blood sugar, but I’m sure the ER did that before he got to you.
Don’t worry about nasty nurses, they are like bad drivers—everywhere, nobody has enough time to worry about all of ‘em. Be good at your job and be a nice person.
With no evidence of a bleed and labs WNL there was no reason not to give Lovenox.
As the other poster mentioned, the head CT without contrast that is done during a code stroke is only to rule out a hemorrhagic stroke…it will not “show” an ischemic stroke. The reason it is done is two-fold, one to look for the bleed, and two, as part of the tPa ‘checklist’. If the pt has a bleed (hemorrhagic) of course tPa is not an option, the pt needs neurosurgery. If the CT does not show a bleed, then the neurologist has to determine if the pt exhibits significant enough deficits to warrant the tPa, and the pt also has to meet a number of other criteria…what time were they last known well, etc.
Regarding the MONA, as you’ve heard, it’s no longer a package deal…
If a pt still has AMS, a lot of times they don’t want you giving narcs because they can’t tell if LOC changes are due to meds or their condition, so they may not let you give morphine.
Supplemental oxygen? Only if needed, if the pt is 94% or better, no need.
Nitro? Well, that depends on the situation…in this case (since you’re in-hospital) I’m getting the EKG stat, then a troponin. If the EKG does not show STEMI, you can slow your roll. You can try a nitro while waiting on the troponin as long as the pt’s BP is above 100 systolic. (Do you have I-stat machines for troponin, or do you have to send them to your lab?) Make sure they have a patent IV (two is better), because if the nitro improves the stenosis and causes hypotension, you’ll be needing a NS bolus stat.
Some docs worry about giving nitro for an inferior MI and some don’t—again, have the IV and NS ready BEFORE giving nitro. Inferior MIs are very sensitive to preload—need to fill the tank.
How do you know if it’s an “inferior” MI…that will come with practice at reading EKGs. If your facility offers an in-person EKG course, I recommend taking it for any bedside nurse. And it WILL be confusing the first time. I found it helpful to take it with a different instructor (I was at another hospital by then) because different teaching styles work better for different people and more things will start to sink in. I'm sure there are good on-line courses too, I just prefer in person learning.
While there is some overlap, the rule of thumb is
Leads II, III, aVF inferior leads right coronary artery
Leads I, aVL, V5, V6 lateral leads circumflex artery
Leads V1 – V4 anterior-septal leads left anterior descending artery
Specifically, V1 & V2 are “septal” leads…septum between the ventricles, and septal perforators are smaller arteries coming off the LAD; V3 & V4 are anterior.
If the Left Main coronary artery is affected, then you will see changes in lateral and anterior-septal leads, because the LAD and circumflex artery branch off from the Left Main Coronary Artery.
Aspirin? Well, again it depends on the EKG and troponin. Assuming no aspirin allergy…EKG show STEMI? Then yes aspirin…325mg is okay, but 4x81mg baby aspirin are better because they are chewable and will start to work faster. EKG show STEMI? No…what's the trop? If EKG neg, but positive troponin, then yes aspirin because you have a non-STEMI and they will be going to the cath lab. If EKG negative and troponin neg, then no need for aspirin—but realistically you would probably give the aspirin while waiting on the troponin result. Why aspirin? In case the patient receives a drug-eluting stent during their heart cath, this prevents our body from attacking the ‘foreign body’ (stent) and causing re-stenosis.
amoLucia
7,736 Posts
TY for the cardiac info.
Just LUV this site for new info! Always something to learn.