Metoprolol

[tchristifulli]

So I had a interfacility transport for a 70 yr female pt who presented to ED with chest pain and left arm pain. Pt had a dual chamber pacemaker with nothing remarkable on EKG. Pt has negative cardiac enzymes as well.
We were called to transport her for a exploratory cath.
Upon our arrival she was symptom free and very alert and friendly. She had a inch of nitro paste on and had already received plavix from the ER. 20 g Iv . Simple transfer capped Iv, 02, monitor.Pt was still hypertensive at 170/90 hr 80s.
Half way into the transport Pts heart rate jumped up to 120. Her left arm started hurting her again and Bp elevated to 190/100. I decided to give 5 mg of metoprolol Iv and saw no change. I waited another 5 min and gave another 5. Hr came down to 64. Bp came down to 120s. Pain was gone within 8 minutes. My question.... Was this proper care? Would you of taken off the paste and started a drip even though she was tachycardic? Why was her pacemaker pacing at 120 bpm?

 

[Carlos Danger]

Technically, I don't think ACLS calls for beta blockade in an ACS patient with non-diagnostic EKG, but it's pretty standard practice everywhere I've been and I think it makes good sense, especially if they remain hypertensive and with a HR above 80 after ntg and analgesia. So IMO, with a SBP in the 170's and a HR above 80 with a potential unstable ACS going on, she should have had the metoprolol before leaving the facility.

As for the HR of 120, are you sure it was her pacer and not her own rhythm?

 

[mycrofft]

So I had a interfacility transport for a 70 yr female pt who presented to ED with chest pain and left arm pain. Pt had a dual chamber pacemaker with nothing remarkable on EKG. Pt has negative cardiac enzymes as well.
We were called to transport her for a exploratory cath.
Upon our arrival she was symptom free and very alert and friendly. She had a inch of nitro paste on and had already received plavix from the ER. 20 g Iv . Simple transfer capped Iv, 02, monitor.Pt was still hypertensive at 170/90 hr 80s.
Half way into the transport Pts heart rate jumped up to 120. Her left arm started hurting her again and Bp elevated to 190/100. I decided to give 5 mg of metoprolol Iv and saw no change. I waited another 5 min and gave another 5. Hr came down to 64. Bp came down to 120s. Pain was gone within 8 minutes. My question.... Was this proper care? Would you of taken off the paste and started a drip even though she was tachycardic? Why was her pacemaker pacing at 120 bpm?

You just gave the civil suit lawyers monitoring the site a frisson. :wub:

You meant a "normal pacemaker tracing" or some such, I'm sure.
A pacer recipient with a "normal" EKG has an issue.

 

[VFlutter]

Why was her pacemaker pacing at 120 bpm?

A pacer recipient with a "normal" EKG has an issue.

That depends on the type of pacemaker and the patient's intrinsic rhythm...


For example a strip of Pacemaker Mediated Tachycardia (PMT)

 

[JPINFV]

You just gave the civil suit lawyers monitoring the site a frisson. :wub:

You meant a "normal pacemaker tracing" or some such, I'm sure.
A pacer recipient with a "normal" EKG has an issue.

Not necessarily. If the patient's current rate is above the pacer minimum, then you won't have anything from the pacer showing.

 

[Grumpy]

Sounds like you did nothing wrong. Lopresssor is a common beta blocker given in ACS. You also can justify giving this drug for many reasons (rate,HTN,ACS).

In the end you gave a drug that did what it was supposed to.

 

[tchristifulli]

Technically, I don't think ACLS calls for beta blockade in an ACS patient with non-diagnostic EKG, but it's pretty standard practice everywhere I've been and I think it makes good sense, especially if they remain hypertensive and with a HR above 80 after ntg and analgesia. So IMO, with a SBP in the 170's and a HR above 80 with a potential unstable ACS going on, she should have had the metoprolol before leaving the facility.

As for the HR of 120, are you sure it was her pacer and not her own rhythm?

Well that's what I thought was weird normally the pacemaker will turn off if the intrinsic rate elevates over lets say 90. But the pacer spikes still showed up before the complex. I know sometimes Pts get nervous in the ambulance and can get tachycardic. My thinking was at 120 we are increasing cardiac work demand and seeing the effects with the complaint of left arm pain. I had to bring down that rate.

 

[JPINFV]

Overdrive pacing maybe?

 

[truetiger]

I think Metoprolol was an appropriate choice here. Pt was experiencing chest pain with an accompany tachycardia and HTN. No reason to think the patient's chest pain wasn't caused by a shortened diastolic time (tachycardia) causing decreased perfusion to the coronary arteries. I might of started an a higher dose of metoprolol though.

 

[Handsome Robb]

I think Metoprolol was an appropriate choice here. Pt was experiencing chest pain with an accompany tachycardia and HTN. No reason to think the patient's chest pain wasn't caused by a shortened diastolic time (tachycardia) causing decreased perfusion to the coronary arteries. I might of started an a higher dose of metoprolol though.

I was thinking something along the same lines. Also the increased afterload the heart is having to work against increases MVO2 which could further the ischemia and pain.

I'd say your treatment was appropriate. Here I'd have to call unless they were a STEMI patient though.

 

[mycrofft]

You just gave the civil suit lawyers monitoring the site a frisson. :wub:

You meant a "normal pacemaker tracing" or some such, I'm sure.
A pacer recipient with a "normal" EKG has an issue.

OP said:
"Upon our arrival she was symptom free and very alert and friendly. She had a inch of nitro paste on and had already received plavix from the ER. 20 g Iv . Simple transfer capped Iv, 02, monitor.Pt was still hypertensive at 170/90 hr 80s. ".

It is not unlikely that I was wrong in this case. Thanks!

I presume the pulse of "80's" was regular then.

 

[tchristifulli]

OP said:
"Upon our arrival she was symptom free and very alert and friendly. She had a inch of nitro paste on and had already received plavix from the ER. 20 g Iv . Simple transfer capped Iv, 02, monitor.Pt was still hypertensive at 170/90 hr 80s. ".

It is not unlikely that I was wrong in this case. Thanks!

I presume the pulse of "80's" was regular then.

Your kinda missing the point of the thread... I asked a question about metoprolol. I did not ask to pick apart my comment and start talking about civil lawyers. If she had a pace maker installed and I say the 12 lead was unremarkable ... Most would put 2 and 2 together and assume it was a paced rhythm.

 

[mycrofft]

Nolo contendre, apologize if I decreased your enjoyment of the thread. Press on.

Was your question answered?

 

[18G]

I agree that metoprolol was appropriate and is indicated in ACS. My regions ACS protocol calls for metoprolol q5mins if chest pain is refractory to SL NTG x2 and first dose of narcotic. We give the standard q5mins up to 15mgs.

I think you provided appropriate care and improved your patient.

 

[Carlos Danger]

I agree that metoprolol was appropriate and is indicated in ACS. My regions ACS protocol calls for metoprolol q5mins if chest pain is refractory to SL NTG x2 and first dose of narcotic. We give the standard q5mins up to 15mgs.

I think you provided appropriate care and improved your patient.

You have to go right to beta blockers after only 2 nitros and 1 dose of narc? That seems unusual.

Do you give additional doses of ntg and narc after you start giving the metoprolol?