When is high too high?

Published

I had a trauma/head injury patient these last 2 shifts with a spike in their vitals signs and wanted to get another opinion -

This patient's baslines usually ran between 120-130 for heart rate, I can't remember what it was in the morning but normal or I would have made note. I checked it again in the afternoon (just scheduled neurovitals, nothing had happened) and the heart rate was going 143-145, all other vitals normal, BP was fine. What do you guys consider a significant change from normal when talking about heart rate? Would you have informed the Doc even though other vitals were normal, or monitor? This patient could only make incomprehensible sounds so I was unable to ask if they felt symptomatic of it.

Up Vote Up Vote ×
Specializes in ICU.

I would certainly let the doc know if a heart-rate was in staying in the 140's.

Up Vote Up Vote ×
Specializes in Cardiopulmonary Stepdown/Cath Lab, ICU.

Was this a Sinus Tachycardia? Was this a maintained rate? If so, that usually requires a stimulus, i.e. pain, fear, etc, was the pt. receiving pain medication. I understand it's hard to assess as the pt. was unable to respond appropriate.

I usually get concerned when a HR stays over 135 for a period of time, in any pt., usually pt. start complaining "their heart is racing" at this point anyway. Any sustained HR over 120 is a lot of work for the heart to maintain and requires a lot of energy.

There are always exceptions, for example I have had severe COPD'ers with baseline HR 120-130s.

So without knowing any pt. history or the exact situation, I would have called and updated the attending. I know in TBI it's the bradycardia you need to be really worried about.

If you were concerned it never hurts to call, or ask another co-worker for a second opinion.

Up Vote Up Vote ×
Was this a Sinus Tachycardia? Was this a maintained rate? If so, that usually requires a stimulus, i.e. pain, fear, etc, was the pt. receiving pain medication. I understand it's hard to assess as the pt. was unable to respond appropriate.

I usually get concerned when a HR stays over 135 for a period of time, in any pt., usually pt. start complaining "their heart is racing" at this point anyway. Any sustained HR over 120 is a lot of work for the heart to maintain and requires a lot of energy.

There are always exceptions, for example I have had severe COPD'ers with baseline HR 120-130s.

So without knowing any pt. history or the exact situation, I would have called and updated the attending. I know in TBI it's the bradycardia you need to be really worried about.

If you were concerned it never hurts to call, or ask another co-worker for a second opinion.

Yes thinking back I should have given something for pain and see if that helped or calmed him down, he had tylenol and ibuprofen. How much of a difference in HR do you monitor before calling the doctor? for example if someone went up by 10 beats/min, 20 beats/min, without immediately obvious reason. Couldn't really find a policy at my site.

Up Vote Up Vote ×
Specializes in Med/Surg,Cardiac.

What was the rhythm?

Up Vote Up Vote ×
What was the rhythm?

Regular, normal sinus as far as I know patient wasn't on telemetry.

Up Vote Up Vote ×
Specializes in Med/Surg,Cardiac.

I'd have called the doc and asked if it was okay to get an EKG and put the patient on tele. I'd also suggest a cardiology consult. There's a reason the HR is so high and it probably should be treated or atleast evaluated.

Was the BP ok? Any other symptoms? Palpitations? Shortness of breath?

I had a situation recently that was similar. I was pulled to a non cardiac floor. I ordered an EKG when I noticed the patient had a HR in the 130s since admission two days earlier and one hadn't been done. The patient was actually in afib with rvr and I called the ortho doc and requested tele and a cardiology consult.

Up Vote Up Vote ×
Specializes in Hospital Education Coordinator.

trust your instincts. The numbers are not as important as the fact there was a significant difference in the range. Yes, call MD and expect to get EKG done and maybe frequent vitals plus what ever else is ordered. Could be embolism or MANY things.

Up Vote Up Vote ×

I would worry about this patient going into V-Tach with a sustained HR in the 140's. They should definitely be on Tele and maybe PO or IV Meds to control the rate. I agree with the previous posts.. trust your gut and call the Doc... and push to have this patient transferred if this HR continues as such.

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

First if the rhythm is sinus/atrial in nature.....v tach would not be a concern. However, I have several questions...

Why is this patient tachycardic at baseline?

What is the nature of the head injury? Bleed? Contusion?

How many days post injury is the patient?

Is the patient confused and agitated?

What is the I/O?

is this patient adequately hydrated?

What was the nature of the injury....

what caused the head injury....

could there be an underlying injury that went un-noticed? (lacerated liver/kidney)

When was the last CBC?

Are they febrile?

When did they last have something for pain?

What is the O2 Sat? RR rate?

and yes...Call the MD

Up Vote Up Vote ×
Specializes in NICU, ICU, PICU, Academia.

Clearly, I've been in peds too long. My thought was "I'm super-happy with a three digit HR that starts with a '1' !!"

Up Vote Up Vote ×

Thanks for all the replies guys! It helps to get some context behind your opinion of what you would do.

Up Vote Up Vote ×
+ Join the Discussion