Friday, July 3, 2009

Mind your QT intervals...

***This is a modified retelling of a real clinical experience. The details have been changed to protect the privacy of the people involved.***

Some time ago, I arrived at work at 0300 to be assigned to (along with a 36 yo M s/p MVC) a 70-somethings male in no apparent distress who was admitted to Neuro ICU per the Neurosurgical service s/p being found down at home by his spouse and presenting with a 'tiny' right parietal subdural hematoma on CT scan of the head w/o contrast enhancement. In report I was told that he had no neurological deficits and that he was hemodynamically stable. The only problems he had overnight were EKG disturbances.
He had a seven beat run of VT and his EKG tracings had changed from a sinus rhythm in the 60's with occasional PVC's to an irregular, bradycardic, sinus rhythm with what appeared to be slightly wide complexes while throwing more frequent PVC's. Cardiology had been updated several times throughout the night, with orders stating that this tracing was acceptable and that nursing should call cardiology if the rate was sustained < 40BPM.
I began my care with some apprehension r/t his rhythms, but more or less eager to perform a thorough neurological assessment to see if I could isolate some small neurological deficit. We proceeded seamlessly through my assessment and had made it up to testing recent memory. I had given the patient three words to remember and I told him that I would ask him to repeat those three words in five minutes. We didn't make it that far.
I had turned to the computer in the room to begin charting my assessment findings when I noticed that the bedside monitor was sounding a red alarm. Bad news. Sustained V-Tach on the monitor. I rushed to the bedside. Weak pulse. Patient rapidly became short of breath, his eyes rolled back. Pulseless.
"Call a code!"
I smacked the code blue button on the wall, dropped the bed into position, slid the backboard under the patient and began compressions (crushing his poor, aged rib bones like toothpicks).
"Call Cardiology! Page Neurosurgery! Did anyone call that code yet? Why haven't I heard it?"
Of course it had all been done. The team in the unit works seamlessly as always.
My co-workers rushed in. Techs were bringing carts, supplies, and making calls. Other RNs were hooking the patient up to the defib, getting the drug box, and starting the code record:
1 amp epinephrine
Still PEA...
1 shock delivered... converts back to PEA: sinus rhythm in the 30s
1 amp atropine
Cardiologist arrives (a USELESS hospitalist had been there the whole time... anyone can read straight from the ACLS protocol... he fled the scene as soon as the Cardiologist arrived and couldn't be reached by phone.)
still PEA, compressions
1 amp epi
1 amp bicarb
weak pulse
transcutaneous pacing initiated to keep HR > 50

The patient was quickly taken to the Cardiac cath lab to get a transvenous pacer.

Outcome: Patient left the ICU after receiving an AICD a few days later. I never took care of him again, but it turns out that somewhere along the way, he did have a CVA... I wish I had the chance to look into that more. Fortunately his deficits from his stroke were very minor, and I have to think that things could have ended up much worse if effective CPR hadn't been started right away and the nursing staff hadn't done such an excellent job of working together for this gentleman.

Of interest: The neurosurgeon was actually angry at us for calling him at four in the morning to let him know that the patient that his partner had admitted was coding. Maybe it's not standard practice to let an admitting physician know when his patient is dying... Beats me.

The bottom line: This guy needed a pacer. His heart decided that 1.25 hours into my shift was the perfect time to issue an ultimatum. He got a pacer.

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