Not your everyday medical call

[rhan101277]

Dispatched to 75 y/o with C/O shortness of breath.

I arrive and he is having some distress but it is minor. He is able to talk in complete sentences. Pt is AAOx3. His left lung field is clear, the right is diminished at the bases. Low grade fever 99.5, no N/V, some coughing w/ clear sputum but this didn't occur while I was there. Complains of dizzyness and "just don't feel right." Daughter reports she gave him a .4mg NTG prior to our arrival for the breathing problem, but he didn't have any pain. NTG was administered about 20 minutes PTA. Just had dialysis this morning, we arrive around 6PM

PMHx: 4 previous CABG, left leg BKA, right leg toes amputated, DM.

Meds: NTG, unable to gather further info.

Vitals: B/P 60/40; HR 47 palpated at carotid; radial pulses absent; monitor shows sinus tachycardia, clearly most of those electrical signals are not causing mechanical action. pulse ox 98% on 4L oxygen NC.

My Tx:

IV x 3 attempts, succeed on last one w/ a 22ga.
I am only able to bolus in 50cc before ED arrival.
Atropine .5mg IVP - increased HR to 84, bp to 74/44, electrical rate 130
I did not pace due to I would have had to pace in the 120's


I see pt later in ED and his bp is 99/64 and he has a 1L of fluid, don't know what else. HR is 88.

While I realize that NTG may have caused this drop it should have started wearing off by our arrival.

Thoughts??

 

[MrBrown]

Tachycardias can be well sustained (in theory) up to the theoretical rate of 220-age so 220-75 is 145.

Rather than some weird electrically dissassociative cardiac problem Brown thinks this patient has a chest infection and that he is bit shut down because of the GTN.

Who gives GTN for a breathing problem anyway, sheesh

 

[johnrsemt]

Family members who are not educated enough in knowing how or when to use Nitro: had one that didn't know how to use peel and stick patches, they taped them to dad's chest. And since the first few didn't work, they taped the entire box of 30 to his chest. It is hard not to laugh at your patients sometimes.

The nitro could have dropped the pressure down, and hearts mechanical response also; and the heart wasn't strong enough on its own to bring the pressure and HR back up to a sustaining amount

 

[usalsfyre]

Was the B/P correlated between automatic NIBP and manual? Because I've found it's very unusual for someone with a MAP in the 40s to not be at least a LITTLE altered. Even if it's just lethargy.

Obviously without seeing the patient we're all flying blind, but based on what you provided I'm going to guess it was dehydration exacterbated by the NTG. He needed some volume, remember bradycardia is a common side effect of NTG.

 

[MrBrown]

Family members who are not educated enough in knowing how or when to use Nitro: had one that didn't know how to use peel and stick patches, they taped them to dad's chest. And since the first few didn't work, they taped the entire box of 30 to his chest. It is hard not to laugh at your patients sometimes.

Oh dear, that bloke would have been, to use a Brownisim, "a wee bit crook"

 

[rhan101277]

Was the B/P correlated between automatic NIBP and manual? Because I've found it's very unusual for someone with a MAP in the 40s to not be at least a LITTLE altered. Even if it's just lethargy.

Obviously without seeing the patient we're all flying blind, but based on what you provided I'm going to guess it was dehydration exacterbated by the NTG. He needed some volume, remember bradycardia is a common side effect of NTG.

Yeah it was, he seemed a bit lethargic.

In a review of 17 cases of hypotensive bradycardia following nitroglycerin administration, no reliable factors to predict this side effect were found. The mechanism is thought to be vasovagal; atropine is an effective countermeasure. Apparently this is rare, I've never seen this in all the times I have given NTG.

Rare cases of A-V block, including complete heart block, thought to be vasovagally-mediated after nitroglycerin administration, have been reported.

Found this info online. Didn't realize that heart block could be a side effect. I knew that hypotension was but I thought that he should have been compensated, ie sinus tach, which he was not. If he had parasympathetic response then I did the right thing.

 

[usalsfyre]

Yeah it was, he seemed a bit lethargic.

In a review of 17 cases of hypotensive bradycardia following nitroglycerin administration, no reliable factors to predict this side effect were found. The mechanism is thought to be vasovagal; atropine is an effective countermeasure. Apparently this is rare, I've never seen this in all the times I have given NTG.

Rare cases of A-V block, including complete heart block, thought to be vasovagally-mediated after nitroglycerin administration, have been reported.

Found this info online. Didn't realize that heart block could be a side effect. I knew that hypotension was but I thought that he should have been compensated, ie sinus tach, which he was not. If he had parasympathetic response then I did the right thing.

Common may have been an exaggeration on my part, what I can say is that in 8 years (including clinicals) of giving NTG at least once a shift (usually) I've seen bardycardia and associated hypotension around half a dozen times after administration. I've never given atropine, only fluid and it's always reversed with in 5 minutes or so.

Completely andecotal, so take it for what it's worth.

 

[rhan101277]

Common may have been an exaggeration on my part, what I can say is that in 8 years (including clinicals) of giving NTG at least once a shift (usually) I've seen bardycardia and associated hypotension around half a dozen times after administration. I've never given atropine, only fluid and it's always reversed with in 5 minutes or so.

Completely andecotal, so take it for what it's worth.

Yeah I was thinking that the medication effect should have worn off by our arrival. Nothing is always by the book though.

 

[Farmer2DO]

.

Vitals: B/P 60/40; HR 47 palpated at carotid; radial pulses absent; monitor shows sinus tachycardia, clearly most of those electrical signals are not causing mechanical action. pulse ox 98% on 4L oxygen NC.

My Tx:

IV x 3 attempts, succeed on last one w/ a 22ga.
I am only able to bolus in 50cc before ED arrival.
Atropine .5mg IVP - increased HR to 84, bp to 74/44, electrical rate 130
I did not pace due to I would have had to pace in the 120's


I see pt later in ED and his bp is 99/64 and he has a 1L of fluid, don't know what else. HR is 88.

While I realize that NTG may have caused this drop it should have started wearing off by our arrival.

Thoughts??

I'm a bit confused. You gave atropine to someone with a sinus tachycardia on the monitor? You suspect electrical impulses that aren't causing mechanical beats. I'm not sure I agree with that; I'd be more likely to suspect weak contractions that aren't causing perfusing beats that can be palpated. I don't think this is a rate problem, I think it's a pump problem, or even a volume problem, that could be due to multiple issues, but I think fluid is the treatment of choice. (I understand how difficult it is in this scenario to achieve that; I might add some tincture of diesel.)

 

[rhan101277]

I'm a bit confused. You gave atropine to someone with a sinus tachycardia on the monitor? You suspect electrical impulses that aren't causing mechanical beats. I'm not sure I agree with that; I'd be more likely to suspect weak contractions that aren't causing perfusing beats that can be palpated. I don't think this is a rate problem, I think it's a pump problem, or even a volume problem, that could be due to multiple issues, but I think fluid is the treatment of choice. (I understand how difficult it is in this scenario to achieve that; I might add some tincture of diesel.)

Yes but treat the patient not the monitor, found out the monitor may be having issues tonight. In the end the atropine did help, it increased B/P and palpatable pulse rate.

First time I have seen anything such as this and each time something new happens it is a learning experience.

 

[vquintessence]

Yes but treat the patient not the monitor, found out the monitor may be having issues tonight. In the end the atropine did help, it increased B/P and palpatable pulse rate.

First time I have seen anything such as this and each time something new happens it is a learning experience.

So the monitor was misbehaving to the point of completely falsifying electrical signals? From my lukewarm armchair, I'd be with usalfyre and just give a healthy dose of vitamin saline. Was the 50cc bolus limited because of your arrival time, so you just skipped to atropine?

Farmer2DO has a good point; just because the pulses aren't all palpable, doesn't mean the heart isn't puming, but rather how effectively. Think of our tachydysrhythmia's; many occasions when you palpate them their pulse is "weak & thready" and sometimes barely detectable, yet the monitor shows them 180+ bpm. We wouldn't ignore the monitor and treat with atropine?

My assumption for your perceptions on this call is that there was a signifacant focus on hemodynamic status (which is by all means a necessity), yet the cause of the hemodynamic compromise was misidentified. From the scenario as posted, it seems the pt was afflicted with a particular form of distributive shock (i.e sepsis), that was thrown way into the decompensated zone when the well meaning (but misinformed) relative dosed the pt with a vasodilator.

 

[austinmedic2004]

To add, Atropine is given for an ELECTRICAL rate less than 60, not a palpated rate or even an inability to palpate for lack of perfusion. The treatment of choice in this case, according to the information you presented would be fluids, keeping in mind the patients dialysis and extreme potential for fluid overload. The next step would be a pressor (dopamine or levophed) depending on your local protocols.

 

[Aidey]

Also, keep in mind that dialysis patients may have had multiple vascular surgeries on their arms in order to place fistulas and grafts. They can have decreased peripheral perfusion without having a systemic problem. Google "steal syndrome", and that should give you some more info. Some people have "dead" accesses that don't work anymore, on some of these patients it is ok to do a BP or blood draw on that arm, but they still may not have a pulse in the normal spot.