Lopressor or No'pressor

[tydek07]

We get called to a local nursing home for a female that is weak, increased temp, lethargic, and SOB. On scene we find a 72yo female laying supine in bed with staff in the room. Staff stated that pts condition has been deteriorating for the past couple days, but do not know when it exactly started.

Staff stated that pts mental status has deteriorated today and she started to get tremors. They had gotten a temp of 103 prior to our arrival. They mentioned that the dosage of pts digitalis has been changed recently (Do not know what the old dose was). Oh, they also through in there that pt may have had a stroke yesterday, but never got seen by a physician.

Hx of CHF, A-Fib, Hypertension, and mental retardation. Staff stated that pt does not usually talk, but is alert and able to follow commands. She is usually ambulatory without assistance.

Pt was responsive to verbal stimuli. She would open her eyes when we said her name, but would not follow simple commands. Breathing at 12/min, HR of 150ish, BP of 150/P. Move her onto our cot and load into ambulance.

Once in ambulance we did further assessment and treatment (not listed in any order here):

• 4-Lead (A-Fib 150-200)
• 12-Lead (Unremarkable)
• BGL (186)
• IV (18 gauge w/ NS WO)
• Vitals (B/P 142/78, O2 sat 98% of 6L via NC)
• Eyes: PEARL, CMS x4, Lung sounds: Deminished in lower lobes

Start transporting to ER. My plan of attack is to give pt fluid bolus and see how that effects her HR. I know that an infection will increase HR and to try fluids first. The A-fib was staying around the 150-170 range to start with, would go up to the 200's for short periods of time.

I have given 500ml of fluid and recheck vitals. Vitals are now: HR 180-220, BP 108/49, O2 @ 98%, Resp 12.

Now I am thinking, Should I control the rate with Lopressor? Something is telling me to hold off on that and give MC a call. So I give MC a call, tell the doctor the situation and pts condition. He tells me to not give the lopressor and to continue fluid therapy... Good thing I called B)

Anywho, transport pt to ER... show up with vitals of: HR 200-220, BP 104, O2 @ 96%.

I go and talk to the doctor that had answered the phone earlier. He said in pts like this to hold of the drugs until you have given at least 1.5-2L of fluids to them, then consider treating the rate, but just consider. I told him that I know infection/sepsis will cause an increased HR and to try fluids first... but how do I know when enough is enough and try to fix the rate problem? Of course, before he can answer he gets a phone call.

So my question is: When do you stop trying fluids and switch over to rate control in pts like this? One of two things will happen 1) Lower the HR and stable things out or 2) Lower the heart rate... along with everything else.

Sorry this is so long, just had to get most of the info in there... I may/probably have forgotten to tell you guys something, so just ask me what you need. Hope you can read through my grammar errors... typing this up quick.

Thanks,
tydek

 

[emtjack02]

So my question is: When do you stop trying fluids and switch over to rate control in pts like this?[/B] One of two things will happen 1) Lower the HR and stable things out or 2) Lower the heart rate... along with everything else.

Well generally I'd say after a liter, but if she does have a source of infection then she will probably need several more liters but you also can't start pressors if you let the pressure drop much more(d/t HR). Although since you lose something like 30% of your stroke volume once your rate is above 130's and you were clearly above that I would think about controlling the rate. I would suggest amiodarone if I knew a little more.
Even with 500ml in I think I would have been leaning toward whatever rate control protocol you have.

 

[tydek07]

Well generally I'd say after a liter, but if she does have a source of infection then she will probably need several more liters but you also can't start pressors if you let the pressure drop much more(d/t HR). Although since you lose something like 30% of your stroke volume once your rate is above 130's and you were clearly above that I would think about controlling the rate. I would suggest amiodarone if I knew a little more.
Even with 500ml in I think I would have been leaning toward whatever rate control protocol you have.

Yah, my thought was give 500cc and then see where she stands. I was just about to draw up the Lopressor, but something in my gut was telling me to call MC. So idk, and this guy use to be our medical director... so ? haha

 

[emtjack02]

Have you been able do do any follow up on her?

 

[tydek07]

Have you been able do do any follow up on her?

No I have not, it was our last call for the day. Hopefully I can follow up a little tomorrow... but it tends to be hard to follow up on these pts.

 

[tazman7]

I guess im kinda confused on why you gave a fluid bolus? Just wondering why? I wouldnt have thought to give a bolus with her having chf and a pressure of 150.. unless of course she was dehydrated or something along those lines.

how were lung sounds? skin parameters?

 

[tydek07]

I guess im kinda confused on why you gave a fluid bolus? Just wondering why? I wouldnt have thought to give a bolus with her having chf and a pressure of 150.. unless of course she was dehydrated or something along those lines.

how were lung sounds? skin parameters?

staff stated that pt had not been getting any fluids lately (how long, who knows how long), and her urine output had been decreased. There was no sweating with the high temp. I figured I would closely monitor pt and do fluid replacement. Her lungs were slightly diminished in the lower lobes, just slightly. Lung sounds did not change during or after the fluid bolus.

 

[tazman7]

staff stated that pt had not been getting any fluids lately (how long, who knows how long), and her urine output had been decreased. There was no sweating with the high temp. I figured I would closely monitor pt and do fluid replacement. Her lungs were slightly diminished in the lower lobes, just slightly. Lung sounds did not change during or after the fluid bolus.

ok now it makes sense. thanks for clarifying

Plus i never knew or thought fluid would make the pressure drop..

 

[fma08]

I know I've been out of the game for a little bit, but initial BP of 150/p, then 142/78, then after the 500ml bolus, 108/49, then 104 showing up at ER after... however many mls of saline... and rate up from 150's to 200-220's Something's going on there IMO. Is that normal in infection/sepsis patient's? I would have been leaning toward rate control there too...

 

[tydek07]

I know I've been out of the game for a little bit, but initial BP of 150/p, then 142/78, then after the 500ml bolus, 108/49, then 104 showing up at ER after... however many mls of saline... and rate up from 150's to 200-220's Something's going on there IMO. Is that normal in infection/sepsis patient's? I would have been leaning toward rate control there too...

As I was going to, but the Doctor said no. Even after I brought her in and he saw her for himself (as we walked by) he still said to not do it in cases like her. I hope I can get back there and talk more about it with him... but he said this is all most likely causes by sepsis and dehydration... I just don't know, I would have most likely pushed the Lopressor if I had not been able to reach MC.

--But as I said before, something in my gut was telling to call MC and get a second opinion.

 

[fma08]

Let me know what Dr. K says, it just seemed weird to me for just being dehydration/sepsis, especially for how her pressure was behaving in that short time you were with her, did her LOC change at all in that time?

 

[tydek07]

Let me know what Dr. K says, it just seemed weird to me for just being dehydration/sepsis, especially for how her pressure was behaving in that short time you were with her, did her LOC change at all in that time?

LOC did not change... for better or worse. Her B/P was going up and down and all over the place... I just put in the drastic changes, and initial and last BP

 

[emtjack02]

I know I've been out of the game for a little bit, but initial BP of 150/p, then 142/78, then after the 500ml bolus, 108/49, then 104 showing up at ER after... however many mls of saline... and rate up from 150's to 200-220's Something's going on there IMO. Is that normal in infection/sepsis patient's? I would have been leaning toward rate control there too...

I am not sure what her source of infection would have been although something as simple as a UTI can cause urosepsis as you probably know. These pt can get pretty shocky and I have personally given around 6L of fluid before they were completely Hemodynamically stable. The current trend now is fluid fluid fluid, we can always (dont want to say it) give lasix if we really overload them. Again this is hypothetical about all the fluid if she wasn't septic. If she was plan old dehydrated I would have been surprised if the 500 or 1L didnt so some type of improvement but the fact that she was up in the 220hr and down to 104 that is a drop of 40mmHg and that can be considered HoTN.

 

[MSDeltaFlt]

We get called to a local nursing home for a female that is weak, increased temp, lethargic, and SOB. On scene we find a 72yo female laying supine in bed with staff in the room. Staff stated that pts condition has been deteriorating for the past couple days, but do not know when it exactly started.

Staff stated that pts mental status has deteriorated today and she started to get tremors. They had gotten a temp of 103 prior to our arrival. They mentioned that the dosage of pts digitalis has been changed recently (Do not know what the old dose was). Oh, they also through in there that pt may have had a stroke yesterday, but never got seen by a physician.

Hx of CHF, A-Fib, Hypertension, and mental retardation. Staff stated that pt does not usually talk, but is alert and able to follow commands. She is usually ambulatory without assistance.

Pt was responsive to verbal stimuli. She would open her eyes when we said her name, but would not follow simple commands. Breathing at 12/min, HR of 150ish, BP of 150/P. Move her onto our cot and load into ambulance.



Once in ambulance we did further assessment and treatment (not listed in any order here):

• 4-Lead (A-Fib 150-200)
• 12-Lead (Unremarkable)
• BGL (186)
• IV (18 gauge w/ NS WO)
• Vitals (B/P 142/78, O2 sat 98% of 6L via NC)
• Eyes: PEARL, CMS x4, Lung sounds: Deminished in lower lobes

Start transporting to ER. My plan of attack is to give pt fluid bolus and see how that effects her HR. I know that an infection will increase HR and to try fluids first. The A-fib was staying around the 150-170 range to start with, would go up to the 200's for short periods of time.

I have given 500ml of fluid and recheck vitals. Vitals are now: HR 180-220, BP 108/49, O2 @ 98%, Resp 12.

Now I am thinking, Should I control the rate with Lopressor? Something is telling me to hold off on that and give MC a call. So I give MC a call, tell the doctor the situation and pts condition. He tells me to not give the lopressor and to continue fluid therapy... Good thing I called B)

Anywho, transport pt to ER... show up with vitals of: HR 200-220, BP 104, O2 @ 96%.

I go and talk to the doctor that had answered the phone earlier. He said in pts like this to hold of the drugs until you have given at least 1.5-2L of fluids to them, then consider treating the rate, but just consider. I told him that I know infection/sepsis will cause an increased HR and to try fluids first... but how do I know when enough is enough and try to fix the rate problem? Of course, before he can answer he gets a phone call.

So my question is: When do you stop trying fluids and switch over to rate control in pts like this? One of two things will happen 1) Lower the HR and stable things out or 2) Lower the heart rate... along with everything else.

Sorry this is so long, just had to get most of the info in there... I may/probably have forgotten to tell you guys something, so just ask me what you need. Hope you can read through my grammar errors... typing this up quick.

Thanks,
tydek

First off, you're picking a pt up from a nursing home; AKA: launching pad. I generally take their reports with a grain of salt.

Now for PMH of HTN: what's her normal BP on meds? Also with A-Fib, we all know you're not going to change a chronic condition. And with her temp and tachy, odds are her HR will generally stay that way until the infection is gone, so long as that is the only thing wrong with her. The older we get, the less we are able to adapt to any changes especially with adding any chronic problems, and she has a list.

Also, the nursing homes I've seen typically have two types of infections going on inside their walls: MRSA and VRE. Her breath sounds and UO were decreased. I'd start looking at UTI that has progressed to possible pneumonia cross-contaminating her heart making it go faster. Dehydration from infection can also do this.

I generally wouldn't start looking at decreasing HR until after 1.5-2L and/or something else was out of whack. Remember 500cc isn't much.

Hope you washed your hands.

 

[maxwell]

Ah, I love these questions.

We're on digitalis. Icky.
We might be septic. Oy vey.
Patient has a complex medical history. Of course.

Beta blockers and sepsis is frequently evaluated (http://www.ncbi.nlm.nih.gov/pubmed/18636043). However, I was always taught *not* to give beta blockers in sepsis for obvious reasons - even though she was hypertensive! CHF doesn't mean don't give volume. It means don't give too much volume (lest it come back out of their mouth!). It's easier to take off volume than it is to give it (just get the volume on board give lasix later prn!).

I would only really get itchy about the HR if the BP dropped. The tachycardia is probably due to sepsis. I'd be okay with about 500-750mL NS. More if she's tolerating it. If I really, really, really had to take care of the rate, I'd give more dig (she's already on it)...it's not that the drug doesn't work, it's that you're not givin' enough of it. CCBs and BBs are dangerous b/c she already has dig on board AND she's septic. No amiodarone, we dont wanna convert her. So, more dig.

 

[Ridryder911]

As previously described, nursing home patients = dehydration = UTI = urosepsis.

I also agree the amount of fluids were nominal in comparrision and usually it is difficult to judge the results in such a short contact time with the patient.

R/r 911

 

[tydek07]

Ah, I love these questions.

We're on digitalis. Icky.
We might be septic. Oy vey.
Patient has a complex medical history. Of course.

Beta blockers and sepsis is frequently evaluated (http://www.ncbi.nlm.nih.gov/pubmed/18636043). However, I was always taught *not* to give beta blockers in sepsis for obvious reasons - even though she was hypertensive! CHF doesn't mean don't give volume. It means don't give too much volume (lest it come back out of their mouth!). It's easier to take off volume than it is to give it (just get the volume on board give lasix later prn!).

I would only really get itchy about the HR if the BP dropped. The tachycardia is probably due to sepsis. I'd be okay with about 500-750mL NS. More if she's tolerating it. If I really, really, really had to take care of the rate, I'd give more dig (she's already on it)...it's not that the drug doesn't work, it's that you're not givin' enough of it. CCBs and BBs are dangerous b/c she already has dig on board AND she's septic. No amiodarone, we dont wanna convert her. So, more dig.

Yes, I know I do not want to convert her, but to slow the rate down. Last thing she needs is someone to risk stroking her out^_^ We only carry Lopressor for uncontrolled A-Fib. Her BP was slowly dropping as her HR was increasing. Went from staying around 160 to staying around 210.

My question is, if I were out in the county with a pt like this (had a longer transport time then I did) and her HR kept increasing and BP kept decreasing... no matter how much fluid I was pushing... When do you start to think about rate control? It would be a tough decision to make I think. Like I said before, it would do one of two things: 1) Lower HR and stable out BP or 2) Lower HR and take the BP with it.

Could this not just be a cardiac case, instead of being caused by the sepsis, since her Dig was recently changed? I think so, but no way to tell 100%

Thanks

 

[ResTech]

Would this pt. be a candidate for diltiazem since the pt. had an uncontrolled A-fib around 200 with low B/P given her nomal hx of HTN? just curious why a beta blocker would be given over diltiazem in a pt. like this?

 

[triemal04]

Would this pt. be a candidate for diltiazem since the pt. had an uncontrolled A-fib around 200 with low B/P given her nomal hx of HTN? just curious why a beta blocker would be given over diltiazem in a pt. like this?

Probably because they don't have cardizem; a lot of places switched to alternative drugs when the powder filled syringes went away. And giving cardizem to someone taking digitalis isn't the best idea, though depending on who you talk to it's not a 100% contraindication.

Personally, and based on previous similar cases and the field and in-hospital treatment, this pt needed, and may very well have gotten both. Was she septic and dehydrated? Pretty damn likely, and needed a lot of fluid. But a heartrate as high as hers...not good, and not going to be sustainable for long periods of time. As old as she is, her max heartrate isn't much more than 150, so if it's actually closing in on 200 (hopefully with afib you were checking her pulses and doing your own count) it needs to be slowed down. Replace the missing fluid, but lower the heartrate at the same time so that it can effectively move that fluid and prevent any further damage.

 

[emtjack02]

Yes, I know I do not want to convert her, but to slow the rate down. Last thing she needs is someone to risk stroking her out^_^ We only carry Lopressor for uncontrolled A-Fib. Her BP was slowly dropping as her HR was increasing. Went from staying around 160 to staying around 210.

My question is, if I were out in the county with a pt like this (had a longer transport time then I did) and her HR kept increasing and BP kept decreasing... no matter how much fluid I was pushing... When do you start to think about rate control? It would be a tough decision to make I think. Like I said before, it would do one of two things: 1) Lower HR and stable out BP or 2) Lower HR and take the BP with it.

Could this not just be a cardiac case, instead of being caused by the sepsis, since her Dig was recently changed? I think so, but no way to tell 100%

Thanks

I think that is a good observation especially she has some mild renal dysfunction as you mentioned she had not been urinating normally.