Hypotension Causing Nursing Hypertension

Hypotension Causes: Three Cases Of Severe Hypotension and Their Dramatic Response To Treatment.

I’m almost going to print this up and drop it in a couple of hospitalist’s mail boxes as they completely buggered their management of the hypotensive patient.
So here’s the story…
50-odd year old dude comes in with bilateral foot wounds, both medicine and podiatry are seeing him.  They start antibiotics and aggressive debridement of the said foot wounds.  To complicate matters, dude is “fluffy”.  Y’know, 400+ and we can’t tell if he is edematous or not.  It’s all fluff.  Instead of thinking sepsis, they’re thinking he needs to be diuresed.  Considering a history of CHF, not a bad idea.  But as he’s getting massive doses of IV Lasix, we’re talking drip rates in the 40mg/hour range here, his urine output starts to drop.  It dwindles, then nearly completely stops.  Bad sign, right?

As this is happening, his pressures are following the exact same path, dwindling down to nothing over nothing.  We’re talking 60/doppler and his pulse is dandy.   But here’s the thing:  he is completely alert and oriented, talking a mile a minute watching the Food Network.

This goes on for 4 days and 5 nights.  Yes, 5 fucking nights.  The nursing staff would call the the on-call staff, explain the situation and be rewarded with, “Oh, uh, turn off the Lasix.”  or “Uh, um…give him a 500ml bolus of NS.” The staff leave detailed notes in the progress notes about the situation so that they can be reviewed by the next day’s docs, but still nothing is done.  Maybe some more piddly-ass boluses that do a whole lot of nothing, but produce no net effect.

Finally on Day 5 (yes, Day 5) as his kidney function is truly in the shitter (creatinine is like 4.0), his ‘lytes are all wacky, his H/H is crap, he barely has any albumin, he hasn’t made urine in 4 days and has been getting goofy at night needing higher amounts of O2, someone decides to actually DO something.  2 units of packed cells, albumin q8, a couple of decent fluid boluses and dopamine.  Finally.

And as if by magic, he gets a blood pressure.  A real blood pressure, like 120’s/80’s.  He slowly starts to make urine.  His O2 need starts to go back to baseline and he’s no longer goofy.  Podiatry decides that now that he is stable it is time to do surgery to lop off the now gangrenous foot and get on with definitive care.

Here’s the thing:  we could have fixed him on night 1 had the on-call doc been willing to look and realize something was not right.  Could we have called a Rapid Response?  Yes, but he wasn’t truly in need of it.  He was relatively stable, with the exception of no blood pressure and no urine.  Besides, we figured that we could manage him on the floor without the ICU.

No one seemed to be cognizant of the fact he was in septic shock from those nasty feet of his.  That is until a prog note was written post-surgery that basically said, “acute on chronic renal failure and septic shock.”  Finally someone got it.

Kind of weird

It’s kind of weird to see a co-worker looking at your blog while at work and having no clue that the author is sitting less than ten feet away.  Or at least they didn’t say anything about it..

Oh yeah, it looks like Mr. Black Cloud is back.

Why do patients try to die right before shift change?  Don’t they know the last thing I want to do before I go home is send them to the Unit.  Well, I wanted to send this guy to the Unit, he was Sick (notice capital S?).   But why at all times to crump than at 6am?  It must be my luck.

Being Prepared

A 30-something year old male presented to the ED of an outside hospital complaining of palpitations that had been occuring intermittently for about a month.  When he had awoke that morning they were present and had not abated as they had in previous instances, so he went to the ED.  No prior medical history, no medication, no alcohol, tobacco or illegal drug use was reported.  The ED physician contacted a cardiologist at our institution for transport of the patient and admission to cardiology.  The patient’s heart rate was in the 160’s and above, but he was hemodynamically stable, nonetheless an antiarrhythmic drug was started and his heart rate slowed prior to transport.

After an hour and a half transport from the outside hospital the patient arrived and was placed on telemetry.  He was noted to have a rapid heart rate in excess of 190 beats per minute.  Subsequently the following 12-lead EKG was obtained.

As you can see, the heart rate is actually exceeding 200 BPM in this shot.  No P waves are seen as either they aren’t present or the rate is too fast and they blend into the QRS.  But how could a guy who’s rate had been controlled prior to leaving the oustide hospital suddenly ramp up?  Well, if you run out of the drug, in this case procainamide, halfway through transport, you tend to have problems.  Evidently, the medics misjudged the length of transport and left with less than half a bag, which at the rate of the infusion was no going to last them all the way to our facility.  So they ran dry en route and this gent’s heart rate started to go back up as the procainamide wore off.

Needless to say, it was restarted ASAP.  After a loading dose and about 15 minutes on the infusion, his 12-lead looked like this:

So what’s going on with this guy?

If you guessed WPW, you would be correct.  Notice the delta wave that is present, most notably in leads II and III.  Coupled with the rapid rate it is a near classic presentation of WPW.  But what is it?  Wolf-Parkinson-White Syndrome is classified as a pre-excitation arrhythmia where electrical impulses leaving ther SA node travel through an accessory bundle of nerve fibers called the bundle of Kent and travel directly to the ventricle, usually the left, sparking a depolarization before the regular impulse travels through the AV node, or pre-exciting the ventricles.  Notice the short PR interval that leads into the delta-wave of the QRS, this is the electrical stimulus traveling through the accessory pathway to the ventricles.  Typically, the bundle of Kent is present in the fetus, but then is electrically isolated by furhter development, in individuals with WPW, this didn’t happen.  When patients are ina normal sinus rhythm, the haert rate can remain controlled, but in people in atrial fibrillation or atrial flutter, the rapid, chaotic atrial impulses are conducted directly to the ventricles resulting in heart rates up to 300 bpm and usually subsequent arrest.  As you can see there though, just because you’re in normal sinus rhythm doesn’t mean your rate can’t rapidly rise.  Treatment of individuals with WPW can be complicated especiallywhen they present with AFib, as normal pharmacological treament, calcium channel blockers, beta blockers, tend to reduce the conduction through the AV node allowing the impulses through the accesory bundle to maintain and even accelarte the heart rate.  In cases like this patient, antiarrhythmics, like procainamide and amidarone can be used to control the heart rate.  Typically, and in this case, a trip to the EP lab is in order to have the accessory bundle mapped and ablated thereby blocking the pathway.

Here’s a couple of good links for WPW:

Wolf-Parkinson-White Syndrome – Wikipedia

Wolf-Parkinson-White Syndrome – eMedicine

A Little Cardiology Geekery – A Day in the Life of and Ambulance Driver

Happy Ending?

No.  Not that kind.  But a happy ending to a code.  It’s rare.  I’ve seen it now only twice (and a third may be underway, but that’s for another post).  Most of the Codes we have on the floor do not end well.  It either ends in the patient being pronounced on the floor, or later on that night, or sometimes week in the Unit.  Our Rapid Responses seem to have better outcomes, but then again, folks usually aren’t dead when we call a RRT.

The other night was going along as planned.  Assessments and vitals, med and insulin being handed out like candy when I walk out into the station from the med room.  You could tell something was afoot, there was just a buzz, almost an anticipatory buzz that something might happen.  Hoping not, but sometimes you just know something bad was coming.  We knew one of our co-workers had a patient who was starting to decompensate, badly, but was still stable.  I had run into her in the med room about an hour back and learned what was up, but she was holding her own.  John, as I’ll call him, had been admitted for pulmonary edema, spent a night in the Unit and come up to us in the afternoon.  He was going for an angio the next day, but was becoming increasingly short of breath, and his BP was way up, like 190’s over 100’s.  So I decide to go check on her.  Sometimes just having someone pop their head in to check on you when you’re in a situation can be stressful (see the landing scene in Airplane), but in others, it’s comforting to know you’re not alone.

I get in the room and look over at John.  He does not look good.  He’s sitting up at the side of the bed, in a semi-tripod sort of position, non-rebreather mask on, and working pretty hard.  I glance down at the portable pulse oximeter on the bed beside him; it reads 78%.  On 15L NRB.  Not good.  Angie, the nurse looks at me, “Let’s get him back into bed, see if we can get him breathing better.”

We move him back, but as we’re getting him settled, he lolls his head back.  “Shit!”  I think.  “I’m going for the cart, you might want to call an RRT”  I say as I dash out the room.  Luckily, John’s doc is still at the station, as I blow past him, “You really need to go see John, he’s crashing quick!”

Down the hall as I hear the clarion call of the overhead calling out for an RRT.  I look at the other nurse’s station and make eye contact with my charge nurse and say, “You might want to join us, we’re having a little fun down here!”  Totally calm, totally collected.  Her jaw drops, but I’m already down the hallway with the cart.  Twenty feet down I hear a Code being called overhead and see the unit secretary gesturing violently to “get my ass down here, now!”

The other staff are pulling furniture and family out of the room as I run the cart inside.  The doc is at the bedside as we hook John up to the monitor.  We’ve got a pulse, but his beating is getting worse, more wet, more ragged and he’s working very, very hard.  By now the room is filling up with people; RT, ICU nurses, our charge, dietary, other nurses, housekeeping and a couple of residents.  Break the cart open to grab airway supplies.  The doc calls for a Mac 3, which I hand over to him.  Funny thing, I only worked in the ER as a student for 3 weeks, but knew exactly what to hand him and even checked to see if the light was working, almost by reflex, weird.

He tries to intubate, but no joy, tube’s in the stomach.  He calls out, “Can I get some roc (rocuronium, a paralytic)?”   Someone else pipes up, “Don’t you want some sedation first?”  John is bucking now, he was fighting the tube on the first pass and now his pressure is through the roof, 220’s over 120’s, but with a strong pulse and good rhythm, his body is just in survival mode.   Dude was a rock.  The rest of the room was pretty much chaos.  Pharmacy didn’t have Versed with them, so it had to be raided out of Pyxis.  The portable suction machine was about to die.  RT is trying to maintain a patent airway and bag John.  Calamity.  Then anesthesia steps up ad takes over.  Like a captain of a foundering ship, he takes control.  It was intense to see.  Totally cool, calm and collected, he starts giving orders.

He asks for vitals.  The ICU nurses can’t seem to figure out how to cycle the automatic BP cuff and are getting increasingly flustered.  I can’t do it, I’m guarding the only site of access available at the moment.  I look over and my buddy Ken is next to me, contorted taking a manual blood pressure.  He’s tucked under my arm, craning his neck to see the dial on the wall behind anesthesia, and in spite of everything, gets it.  We push nitro and labetalol to bring down his pressures, then Versed to knock him out and now, some rocuronium to paralyze him.  I’m juggling syringes and flushes, wishing I had an extra hand, but somehow keeping them straight.

Now sedated and paralyzed, he gets intubated. But when the stylus is pulled out, a stream of pink frothy liquid comes shooting out of the ET tube.  Massive flash pulmonary edema.  The look on anesthesia’s face is priceless: a mix of awe, wonder and sheer terror, as he had been in the line of fire seconds before.  More meds, start running a nitro drip and we get John packaged for transport.  RT is bagging John sporting the oh-so fashionable face mask provided to them to protect from flying froth.  And off to the ICU we go.

We get John settled into his new bed in the ICU and one of the ICU nurses, who had previously been, well, freaking out, looked over and said, “You guys did a great job up there.”

“Thanks,” I said as I grabbed the bed and our transport monitor along with the other little bits we needed to return and headed back upstairs. Waiting for the elevator I feel the adrenaline slowly staring to fade and the post-rush shakes starting.  When I get back upstairs, anesthesia is still there writing his note, looks up and says, “You guys did a great job in there.”  Wow, twice in five minutes, I guess our floor does have it together.  Talking about it later with Ken, he says, “Y’know, we (our floor’s nurses) were the only cool heads in that room.  You totally calm, it was awesome.”

Fast forward a week.

I figured John had been in pretty bad shape.  I wasn’t expecting to see him sitting in bed as I walked into one of my rooms to introduce myself as his nurse for the night thought.  I said, “You look a heck of a lot better than the last time I saw you!”

“I’m sure” he replied, “But I really don’t remember all that much about it.  Just glad I came out of it OK.”

Well they had done the angio and found he had severe triple vessel disease only correctable through bypass and was schedule for surgery in the morning.  I made sure I spent a little extra time with him that night, just making sure he was comfortable and ready to roll.  He was up bright and early to get prepped for surgery, and for once I didn’t forget to do anything off the checklists. I wished him luck as he slid over to the gurney on his way to the OR and said, “I’ll see you when you get back up here.”

And you know what?  He sailed through surgery and recovery like a champ.  Last I saw him, the day before discharge, he was up, walking around, weak, but doing well.  He ended up going home the very next day.  Like I said, a happy ending.

Inappropriate ICU Transfer of the Week

When folks need to go to the Unit, whether it is an evolving MI, (non)lethal arrhythmia, hemodynamic instability or they just need that higher level of care, we can’t wait to get them off the floor. Last thing anyone on our floor wants is a truly unstable patient lingering in one of our rooms when they needed to be the Unit 20 minutes ago. Sometimes though, you just can’t seem to convince the docs that they need to go and in the same vein, those that really don’t need to go, get sent.

We had a couple of instances of that lately. First, we called a Code on a guy who vagaled on the toilet. He was down to the Unit in less than 15 minutes, albeit already awake and laughing with the transport nurses as he went. At the decision time though, he needed to go. Now.

On the other hand is the patient who is stable but the docs are convinced they require  the advanced monitoring care of the ICU. This happened just the other night.

Let me remind you, we’re a cardiac unit. We deal with post-PCI patients, pacers, rule out MI’s, pre/post-op open hearts, CHFers, arrhythmias (like atrial fibrillation with rapid ventricular response) among other things – like being the largest unit in the hospital and getting overflow patients. When it comes to all things cardiac, we’re the place to be. Guess that’s why the sign over the entrance to our unit says “Cardiology/Cardiac Surgery”.

Anyway. My colleague’s patient was post-chole or some other laproscopic surgery. Nothing too hot and heavy. She goes in to asses her patient (who’s not on tele) and notices her heart rate is rapid and irregular. Being the good cardiac nurse she is, she grabs a12-lead EKG and voila’ – a-fib with RVR. She calls the surgical resident on call who orders some metoprolol to slow down the rate and eventually a diltiazem drip. No biggie to us. We do this all the time. Heck, with our fresh hearts we have an A-Fib protocol where we don’t even have to call the surgeon if the patient goes into fib, as long as they’re hemodynamically stable. We just follow the protocol.

In this case, after the drip was started, blood pressures were 110’s over 70’s, rate in the 80-90’s, good perfusion (warm, pink and intact), making urine, not even short of breath. Totally manageable on our floor. But the surgical resident still wants to transfer. My colleague tries to suggest that it isn’t needed. She did everything but come out and say, “Y’know what? She’s stable. Her rate’s good. She doesn’t need to go.” Not that it would have done any good. So off she goes at 0630 down to the Unit. Her rate on arrival to the unit was 70’s and it looked like her heart was already trying to convert back into normal sinus.

I looked at the ICU nurse and said, “Ten bucks says she’s back up by the end of the day.”

To which she replied, “End of the day? She’ll be back up by noon!”

“Right,” I retort, “if they haven’t given her room away…”

It’s a Murphy’s Law kind of thing: they go when they don’t need to and stay when they do.

And for all you soda drinkers out there, here’s a little bit of science to enliven your day: “What happens to your body if you drink a Coke right now?” Now, off to the fridge, I’m kind of thirsty…