18 Acute Skin Rashes for Nurses to Know (with pictures)

Jul 21, 2021 | 1 comment

18 Acute Skin Rashes for Nurses to Know (with pictures)

Skin rashes are a common reason why patients and parents seek medical care. Skin rashes can look gross and are often uncomfortable – whether they itch, burn, or cause pain.

Many causes of skin rashes are temporary, but some are chronic and can be ongoing.

Understanding the most common types of skin rashes and their treatment will be important, as you will run into skin-related problems in any setting of healthcare.

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Skin Rashes: Taking the History

In order to successfully diagnose a skin rash, you need to know which questions to ask.

Timing is an important factor to consider. How long has the rash been there, does it come and go? Did the rash look different when it first occurred, and how has it changed? If it occurred before, what was it and what treatment worked?

Associated symptoms can be key in making the right diagnosis. Does it itch, burn, or is it painful? Are there any fevers, chills, pain anywhere else in their body?

Related activities that may have caused or worsen the rash should be investigated. This includes things like sunlight exposure, being out in the woods, using a new skin product like shampoos or lotions, or new medications or foods.

Treatments that the patient has already tried should be evaluated, which usually includes OTC creams and sometimes prescribed medications from a previous diagnosis or from another recent healthcare visit. This may be Benadryl cream, steroid cream (like hydrocortisone), moisturizers, etc.

A detailed past medical history and current medications should be evaluated as well.

Meds that are more likely to cause a rash include:

Antibiotics
Anti-epilepsy medications
allopurinol

The Skin Rash Physical Exam

When looking at skin rashes, they are described using various describers which have different meanings and significance.

A lesion is a general umbrella term that essentially means any non-normal “spot” or region.

Macules are lesions that are flat, <1 cm in diameter, and have different pigmentation from the base skin color. These are called patches when they are >1cm.

Macules: Café au Lait, freckles
Patches: Vitiligo

Papules are like macules, except they are raised and palpable, also <1cm, and have different coloring from the base skin color. Lesions >1cm are termed plaques. Pustules are papules with purulent fluid inside.

Papules: Acne, moles, warts
Pustule: Cystic Acne, Folliculitis
Plaque: Psoriasis

Purpura are red-purple discolored lesions that do not blanch. Blanching is when you press on an area of skin and it turns white from capillary compression. Purpura occurs due to leakage of blood into the extra-capillary space.

Vesicles are small papules <1cm that contains clear or bloody fluid. Bullae are bigger than 1cm.

Vesicles: Shingles
Bullae: Bullous pemphigoid

Wheals are elevated irregular-shaped areas of edema that are pale or erythematous. An example of this is urticaria like with an allergic reaction.

These lesions and skin rashes can present in certain patterns and distributions, which can also help you successfully identify the rash.

Skin rashes can be clustered in small groups, grouped together in some fashion, linear (in a line), following the dermatome (termed zosteriform), and even coalescing together. Various rashes have certain patterns which can make the diagnosis easier.

IMPORTANT DISCLAIMER!

The following images are examples of how these rashes present on white and light-skinned individuals. For examples of how these rashes may present in darker-skinned individuals, please check out @brownskinmatters on Instagram.

20 COMMON SKIN RASHES

Allergy-Related Rashes

Contact Dermatitis
Allergic Urticaria
Eczema

Autoimmune-Related Rashes

Psoriasis

Viral Rashes

Shingles
Pityriasis Rosea
Hand-Foot-Mouth Disease
Measles

Fungal Rashes

Intertrigo
Tinea Corporis

Bacterial Rashes

Cellulitis
Folliculitis
Furucle/Carbuncle

Bite-Related Rashes

Bed Bugs
Flea bites
Spider bites
Scabies
Erythema Migrans

Allergy-Related Rashes

CONTACT DERMATITIS

Contact dermatitis is when the skin has a reaction to something that it has come into contact with. 80% of cases are caused by an irritant, and 20% are caused by allergens. Contact dermatitis is the most common dermatologic diagnosis.

Irritant contact dermatitis is very common and often occurs from exposures to heavy metals, strong acids, rubbing alcohol, and certain ingredients in soaps and lotions. Patients often complain of pain or burning with some itching.

The skin will typically look erythematous, dry, and irritated. There may be pustules present as well.

In Allergic contact dermatitis, common causes include nickel, black hair dye, topical medications, latex, and various cosmetics and environmental exposures (like poison ivy or poison oak). Allergic dermatitis tends to be itchier with less pain or burning. There may be vesicles present as well.

Treatment for these includes steroids for the reaction, and benadryl for the itching. If the lesion is smaller, a topical steroid like Triamcinolone 0.5% once daily for 2-4 weeks can be effective. If the lesion is more widespread, systemic steroids can be used like prednisone.

ALLERGIC URTICARIA

Urticaria or hives are itchy raised wheals that are often erythematous or pale. They are often a response to an allergy such as in anaphylaxis, but many cases of urticaria are non-allergic and some are idiopathic (aka we don’t know why).

Allergic urticaria occur after contact with an allergen. These allergens can be in the environment (like dust or pollen), in food (like nuts or dyes), and in medications like with antibiotics. Urticaria can also occur after bug bites and stings.

Treatment for urticaria skin rashes depends on the underlying cause, but in cases of allergic cause includes anthistamines like benadryl, and sometimes steroids like prednisone.

ECZEMA

Eczema, also termed atopic dermatitis, is a chronic allergic-related chronic skin condition which is very itchy.

Ecezema involves very dry skin that is erythematous with oozing and crusting, excoriation from scratching, and eventual lichenification (when the skin becomes thick and leathery).

In adults, eczema skin rashes often occurs on skin flexures like the elbows and behind the knees, on the face, neck, and hands, but can occur anywhere.

All patients with eczema should liberally use a water-based emollient moisturizer like Cetaphil, Aquafor, or CeraVe.

Since eczema is a chronic condition, it cannot be taken away completely, but there are treatments that can help. Depending on the severity of the eczema, lower or higher strength steroid creams can be used once or twice daily for 2-4 weeks.

Low Potency: Hydrocortisone 2.5%
Mid Potency: Triamcinolone 0.1%
High Potency: Usually not prescribed for eczema

Clinical Note: Higher potency steroids on the face or thinner areas of skin have a higher risk for atrophy and permanent discoloration, so use cautiously and for limited amounts of time.

For more severe eczema, topical calcineurin inhibitors can be used as well or even monoclonal antibodies. A dermatologist should be the ones to prescribe these advanced medications.

AUTOIMMUNE-RELATED RASHES

PSORIASIS

Psoriasis is a type of chronic autoimmune skin rash condition. This is characterized by erythematous flaking thick patches of skin. They can be itchy and even burn.

Treatment for psoriasis depends on the severity of the disease, but can range from topical steroids, retinoids, tacrolimus, or at times systemic steroids and immunomodulators.

VIRAL-RELATED RASHES

SHINGLES

Shingles, also called Herpes zoster, occurs from reactivation of inactive varicella virus within the body (the chicken pox virus). Shingles almost always occurs in adults and usually >50 years old.

Shingles begins as an erythematous maculopapular rash that develops fluid-filled vesicles that scab over in 7-10 days and clear up by 2-4 weeks. The rash will follow 1-2 dermatomes (termed zosteriform), and should not cross the midline. Shingles is often very painful and can itch, which may even precede the rash.

Treatment involves pain control. Antivirals like acyclovir can be started within 72 hours that the lesion develops, otherwise they are unlikely to be beneficial.

Shingles is very contagious, especially if any vesicles pop open until the lesion scab over.

PITYRIASIS ROSEA

Pityriasis rosea is a self-limiting rash thought to be secondary to viral infections. Skin rashes and reactions secondary to viruses are termed viral exanthems. This is often preceded by a viral prodrome including headache, malaise, arthralgias, and/or chills.

Pityriasis rosea starts as a herald patch which is a single oval-shaped erythematous macule or patch on the trunk with central clearing. 1-2 weeks later, a christmas tree pattern will appear on trunk with similar smaller lesions.

There is no specific treatment for pityriasis rosea, and only time will cause the rash to resolve. Pityriasis can be itchy so benadryl can help. This is not contagious.

HAND-FOOT-MOUTH

Hand Foot and Mouth disease is a viral rash that occurs due to the Coxsackie Virus A16 and some other enteroviruses.

HFM typically occurs in outbreaks every few years in the summer months.

While HFM usually affects children, it can easily spread to parents and family members via droplets. Adults and teenagers will often have systematic symptoms including fevers, body aches, and flu-like symptoms. HFM may be preceded by upper respiratory symptoms by a few days.

The HFM rash appears on the palms, soles, buttock, and mouth of patients. The oral lesions have football shaped vesicles that are very painful and are on the soft palate, buccal mucosa, gums, and tongue. The posterior pharynx is unaffected.

Skin lesions are red papules with a red halo, then become gray vesicles, then ulcers after the vesicles rupture, then heal 7-10 days later.

Like all viruses, treatment is symptomatic. Antipyretics and NSAIDs for pain and fevers and topical lidocaine for painful oral lesions. Keeping the patient well-hydrated is very important.

In severe cases, the patient can have altered mental status from encephalitis or myocarditis.

MEASLES

Measles, once nearly eradicated, has begun to make a comeback, largely due to the growing Anti-Vax movement. However, since COVID cases have dropped again. The measles, caused by the morbillivirus, causes 150,000 deaths per year worldwide, usually in those less than 5 years old.

The rash itself is an red-brown maculopapular rash that starts 3-5 days after systemic symptoms of severe cough, nasal congestion, red eyes, high fevers, and photophobia.

The rash starts on the forehead and spreads to the face, neck, trunk, extremities. It spreads to the palms and soles in 50% of patients.

Koplik spots are small white spots with red halos in the mouth on the inside of the cheeks that occur early in measles, which is very specific to measles.

Treatment is largely supportive with antipyretics, analgesics, vitamin A, and hydration. More severe cases will need hospitalization and sometimes the antiviral medication Ribavirin.

FUNGAL RASHES

INTERTRIGO

Intertrigo is inflammation and infection of the skin folds, usually in obese individuals with diabetes. This is often a fungal infection, but can have a bacterial component as well.

Candida is the most common fungus, with erythema, scaling, satellite lesions, and foul odor.

Common sites include the groin, axillae, underneath the breasts, and inbetween fat rolls.

These places will often be itchy, burning, and may smell bad.

When in the groin region, this is often called tinea cruris.

Prevention and treatment includes measures to reduce friction, reduce moisture (talcom powder), use of barrier cream or ointment, and wearing breathable fabric.

The fungal infections can be treated with topical antifungals including clotrimazole cream or nystatin powder 2-3x per day.

TINEA CORPORIS

Tinea corporis, also known as ringworm, is a fungal infection of the trunk or extremities. This is spread via skin-to-skin contact with an infected individual or animal, but can also be picked up by fomites. This is also common in athletes like wrestlers and in warm-moist locker rooms where fungus likes to live.

Tinea corporis is a pruritic, round, erythematous or hyperpigmented, scaly patch or plaque with a raised border. They can coalesce together as well. Pustules can appear as well, although not as common.

Treatment inovlves the use of topical antifungals 1-2x/day for 1-3 weeks. An example includes Clotrimazole 1% BID. More severe infections may need oral antifungals.

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Everything you need to know on how to read a rhythm strip!

BACTERIAL RASHES

CELLULITIS

Cellulitis is a local bacterial skin infection. This starts as some sort of breach to the skin barrier (small cut or puncture), and subsequent infection of the skin and surrounding soft tissue.

Cellulitis presents as localized erythema, edema, pain, and warmth to touch. This often presents in a unilateral leg, but can present anywhere on the body.

Cellulitis may be associated with systemic symptoms such as fevers, chills, and generalized malaise. Sometimes abscesses can form.

Cellulitis is treated with PO antibiotics, but if significant systemic symptoms, high risk, or severe disease – IV antibiotics may be necessary.

PO: keflex 500mg QID x 7 days
IV: Ancef 1gm q8h

MRSA is resistant to certain antibiotics such as those above. Risk factors for MRSA include a personal history of MRSA, recent hospitalization, surgery, or nursing home stay; recent antibiotic use, immunocompromised, open wounds, etc.

The following antbiotics should cover MRSA:

PO: Bactrim, Clindamycin, or Doxycycline
IV: Vancomycin, Linezolid, or Daptomycin

FOLLICULITIS

Folliculitis is a bacterial infection of the hair follicle, usually caused by staph aureus.

This causes a tender, red, elevated papule/pustule. These skin rashes can occur anywhere where hair follicles are. This is common after hot tub use in young healthy individuals.

If mild, folliculitis is self-limiting and may not need any specific treatment. A topical antibiotic like Mupirocin ointment TID x 7 days can be used.

More significant folliculitis can be treated with PO antibiotics like dicloxacillin, keflex, or another antibiotic with good gram positive coverage.

FURUNCLE & CARBUNCLE

A furuncle is a larger painful infection of a hair follicle which is deeper than folliculitis. Another term for furuncle is a boil.

A furuncle is a well-circumscribed painful erythematous lesion which is full of purulent fluid. This can extend into the dermis and soft tissue, leading to skin abscess. These often occur in areas of friction such as the buttock, axillae, extremities, breasts, etc.

Multiple furuncles can coalesce together to form a carbuncle.

Smaller lesions can be successfully treated with warm compresses, but larger more significant lesions will need treated with Incision & Drainage.

PO antibiotics are often given, however may not be necessary if I&D is performed. They should be given if there is cellulitis present, significant comorbidities like diabetes, with systemic symptoms, or unreliable follow-up.

PO antibiotic choices are the same for cellulitis, except MRSA should probably be covered regardless.

Personal hygeine should be encouraged as this can help prevent skin abscesses from occurring.

BITE-RELATED SKIN RASHES

There are plenty of bugs that can bite, sting, and infest our skin, leaving skin rashes behind.

BED BUGS

Bed bugs inhabit typically houses and beds that are somewhat unclean (very common in group homes and homeless shelters). They feed on blood which causes a local reaction in the skin.

While not everyone reacts the same to these bites, they will typically present as itchy papules or wheals, macules, or bullae. They have a habit of appearing in a linear pattern, indicating the bed bug’s trajectory. These can show up when the patient wakes up but can take a few days.

Treatment includes benadryl for itching, and if there is significant itching, a low to medium potency topical steroid can be used.

Maintaining good hygiene is essential, and a pest service will need to be used to clear out an infestation.

FLEA BITES

Flea bites occur when fleas are transmitted from animals to humans. This is usually due to infested domesticated cats or dogs who transmit the fleas to their owners.

When a flea bites, it will cause pruritic papules, most common on the ankles.

An antihistamine like benadryl or zyrtec can be given for itching. Ice packs and calamine lotion can also help with the itching. Topical steroids are usually not necessar but can help.

SPIDER BITES

Spider bites are actually pretty rare, as many spiders do not have fangs strong enough to pierce human skin. They also usually do not bite unless they are provoked or about to be squished.

Most cases of “spider bites” are something else (i.e. furuncle, abscess, MRSA, etc).

When there is a real spider bite – a papule, pustule, or wheal will appear. Two small central fang marks can often be visualized in the center. The most common areas are in the axillae, the waist, and the ankles/feet.

Most spider venoms are benign and only cause a local reaction. Black widows, funnel web, and phoneutria spiders are more poisonous and the patient may have systemic symptoms including body aches, hypertension, tachycardia, abdominal pain, etc.

Brown recluse spiders can cause systemic symptoms, but often causes a more significant local reaction with potential necrosis.

Treatment for simple spider bites involves cleaning the area, and they will spontaneously resolve in 7-10 days. If there is associated cellulitis, appropriate antibiotics should be given as above. More severe reactions may need more supportive care and hospitalization.

SCABIES

Scabies is more common in children but can happen in adults as well. It is also associated with poor hygiene and crowded living conditions similar to bed bugs.

Scabies is not exactly a bite, but rather an infestation of the scabies mite into the patient’s skin where they burrow and lay eggs, leaving behind nasty skin rashes.

Scabies rash appears initially as tiny to small erythematous papules, and will often form vesicles or pustules. They will often present in lines as the mites burrow through the epidermis. This can be easily noticeable in the web spaces of the fingers, wrists, and elbows.

Scabies is very itchy as well, and itching may persist 2-6 weeks after treatment.

Benadryl can help with the itching, but scabies will need treated with Permethrin 5% cream applied to the entire body, left on overnight (8-14 hours), and washed off in the morning. This should be reapplied in one week.

Everything else in the house that could be infested should be cleaned. Bedding and clothing within the last 48 hours should be washed in hot water and heat-dried. Non-washable items should be placed in plastic bags for at least 1 week (stuffed animals, etc).

ERYTHEMA MIGRANS

Erythema migrans is the “bulls eye rash” of early lymes disease.

This rash occurs in about 90% of lymes cases, and occurs 3-30 days after getting bit by a deer tick that carries lymes.

The initial rash will be a small red painless papule, which will expand over a few days and turn into a circular erythematous rash with central clearing and induration. This resolves in weeks if left untreated.

Treatment for this rash is treatment of the underlying Lymes disease. Lymes should be treated with doxycycline 100mg BID x 21 days.

Be sure to have your patient EAT with and directly after doxycycline, as it can cause significant GI upset and pill esophagitis.

You may also like:

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

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Allergy-Related Rashes

Contact Dermatitis
Allergic Urticaria
Eczema

Autoimmune-Related Rashes

Psoriasis

Viral Rashes

Shingles
Pityriasis Rosea
Hand-Foot-Mouth Disease
Measles

Fungal Rashes

Intertrigo
Tinea Corporis

Bacterial Rashes

Cellulitis
Folliculitis
Furucle/Carbuncle

Bite-Related Rashes

Bed Bugs
Flea bites
Spider bites
Scabies
Erythema Migrans

STEMI & NSTEMI: A Nurse’s Comprehensive Guide

Jun 16, 2021 | 5 comments

STEMI & NSTEMI: A Nurse’s Comprehensive Guide

A STEMI is an ST-Segment Elevation Myocardial Infarction – the worst type of heart attack. This type of heart attack shows up on the 12-lead EKG.

An NSTEMI (or Non-STEMI) does not have any ST elevation on the ECG, but may have ST/T wave changes in contiguous leads.

Patients with STEMI usually present with acute chest pain and need to be sent to the cath lab immediately for reperfusion therapy – usually in the form of a cardiac cath with angiography +/- stent(s).

Ruling out a STEMI is the main reason 12-lead ECGs are obtained, and it is critical that you learn to identify them – even as nurses.

While Physicians/APPs should be laying their eyes on ECGs relatively quickly, this isn’t always the case. The sooner a STEMI is identified, the better the chance for survival for the cardiac tissue as well as for your patient!

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CORONARY ARTERY ANATOMY

The coronary arteries lie on the surface of the heart (the epicardium).

These arteries deliver vital blood flow and oxygen to the myocardial tissue to keep the heart perfused and beating.

The three main coronary arteries are the left anterior descending artery (LAD), the circumflex artery (Cx), and the right coronary artery (RCA).

The Right Coronary Artery (RCA)

The RCA travels down the right side of the heart in the groove between the right atrium and right ventricle. The RCA supplies blood to:

Right atria
Right ventricle
Inferior and posterior surface of the left ventricle (85% of people)
SA node (60% of people)
AV bundle (85-90% of people)

The Left Coronary Artery

The Left coronary artery begins thicker and is called the left main coronary artery. This branches off into the LAD and the Cx.

The Left Anterior Descending Artery

The LAD lies on the surface of the heart between the right and left ventricles. It often extends to the inferior surface of the left ventricle in most patients. The LAD supplies blood to:

Anterior surface and part of the lateral surface of the left ventricle
The anterior 2/3 of the intraventricular septum

The Circumflex Artery

The Cx wraps around the left side of the heart in the groove between the left atrium and left ventricle in the back (the coronary sulcus). The Cx supplies blood to:

The left atrium
The other part of the lateral surface of the left ventricle
Rarely the inferior and/or posterior portions of the LV
SA node (40%)
AV bundle (10-15%)

The Posterior Descending Artery

The posterior descending artery usually branches off from the RCA, although less commonly from the Cx. Whichever one does form the posterior descending artery is considered the “dominant coronary artery”.

ACUTE CORONARY SYNDROME

Acute coronary syndrome (ACS) is an umbrella term referring to any condition which causes decreased blood flow to the heart – also known as ischemia. Prolonged ischemia can lead to infarction – which is cell death of the heart tissue.

This cell death causes the release of troponin into the bloodstream, an enzyme that is not usually found in the systemic circulation.

Cardiac ischemia is usually secondary to atherosclerosis which is a buildup of plaque within the coronary arteries. This is usually caused by unhealthy eating habits, obesity, sedentary lifestyle, hyperlipidemia, smoking, and genetics.

This plaque can rupture, releasing contents into the bloodstream which causes a local inflammatory reaction as well as begins a coagulation cascade.

This blood clot can completely occlude an artery – leading to infarction.

A Non-ST segment elevation myocardial infarction (NSTEMI) refers to a complete occlusion of a coronary artery that does not cause ST-segment elevation on the ECG.

While some heart tissue dies, this is usually less extensive than a STEMI. The infarction is usually limited to the inner layer of the myocardial wall.

NSTEMIs will often have nonspecific changes on the EKG. These changes include T wave inversion or ST-segment depression with or without T wave inversion in anatomically contiguous leads. However, NSTEMIs could also present with a completely normal ECG.

Troponin levels will be elevated indicating myocardial cell death. However, the ECG does not have ST-segment elevation.

An ST-segment Elevation Myocardial Infarction (STEMI) refers to a complete occlusion of a coronary artery that causes more significant infarction that extends the entire thickness of the myocardium (termed transmural).

A STEMI will have ST-segment elevation in at least 2 contiguous leads on the ECG.

Where this elevation occurs will indicate which heart wall is infarcting, as well as within which coronary artery.

ISCHEMIA & INFARCTION (STEMI) ON THE ECG

The ST-segment is the segment on the ECG right after the QRS segment and before the T wave. This represents the initial phase of ventricular repolarization and should be at the isoelectric line.

The TP-segment should be used as the isoelectric baseline, but you can use the PR segment if the TP is difficult to see.

The J-point is the point on the ECG where the QRS complex meets the ST segment. This is important for recognizing ST segment elevation.

ST-SEGMENT DEPRESSION

ST-segment depression most commonly identifies cardiac ischemia, as well as reciprocal changes in an acute MI.

It can also indicate heart strain, digitalis effect, hypokalemia, hypomagnesemia, or even be rate related. However, these changes are usually more diffuse as opposed to localized to at least 2 contiguous leads.

ST-segment depression is defined as ≥0.5 mm depression (1/2 small box) below the isoelectric line 80 ms after the J-point (2 small boxes).

Horizontal and Down-sloping ST-segment depression are more specific to cardiac ischemia, whereas up-sloping tends to be less serious although still could indicate ischemia.

De Winter T waves can be seen in 2% of acute LAD occlusions without significant ST-segment elevation. Instead, there will be ST-segment depression at the J-point with upsloping and tall, symmetric T waves in the precordial leads (V1-V6).

ST-SEGMENT ELEVATION

ST-segment elevation usually indicates myocardial infarction when appearing in at least 2 contiguous leads.

Other possible causes of ST-segment elevation include coronary vasospasm, pericarditis, benign repolarization, left BBB, LV hypertrophy, ventricular aneurysm, Brugada syndrome, ventricular pacemaker, increased ICP, blunt chest trauma, and hypothermia.

ST-segment elevation is defined as ≥1 mm elevation (1 small box) above the isoelectric line at the J-point. However, in leads V2 and V3, it needs to be > 1.5mm in women, > 2mm in men >40, and > 2.5mm in men < 40.

Concave ST elevation is considered less ominous and sometimes can indicate benign variant called early repolarization, especially when diffuse.

Convex upward ST elevation is almost always indicative of a large MI. This is termed “tombstoning”.

Q WAVES

Q waves are the initial positive deflection of the QRS complex indicating septal depolarization. These are normal in all leads except V1-V3.

Pathologic Q waves are abnormal Q waves that indicate underlying pathology – usually a current or previous MI.

Pathologic Q waves are defined as >40ms wide (1 small box) and >2 mm deep (2 small boxes).

Any Q waves seen in V1-V3 are always pathologic.

Pathologic Q wave

Q waves can begin hours to days after an infarction begins, and can last for years, even forever.

LBBB OR VENTRICULAR PACED

Recognizing ST-segment elevation or depression can be difficult in the case of a left bundle branch block (LBBB) or ventricular paced rhythm. This is because there is normally some associated ST-elevation and discordant T waves with these conduction abnormalities.

To determine possible ischemia or infarction in a patient with these conduction abnormalities, one of the following should be present:

ST-segment Elevation > 1mm in a lead with a positive QRS complex (concordant ST elevation)
ST-segment depression >1mm in V1, V2, or V3

These are not always present, but if they are – you should highly suspect ACS in a patient with a pre-existing LBBB morphology.

This is why a new LBBB and acute chest pain or SOB is concerning for acute MI.

You may also like: “How to Read a Rhythm Strip”

STEMI PROGRESSION

STEMIs typically have a normal progression that will be seen on the ECG.

Hyperacute T waves are first seen, which are tall, peaked, and symmetric in at least 2 contiguous leads. These usually last only minutes to an hour max.

Then, ST-segment elevation occurs in at least 2 contiguous leads at the J-point, initially concave, and then becomes convex or rounded upwards.

The ST-segment eventually merges with the T wave and the ST/T wave becomes indistinguishable. This is a “tombstone” pattern.

Reciprocal ST depression may be seen in opposite leads.

The ST segment then returns to baseline after a week or so.

Q waves eventually develop within hours to days, followed by T wave inversion which could be temporary. Over time, the Q wave deepens.

STEMI LOCATION

STEMIs are classified based on where they are located anatomically – so which leads are they are affecting on the ECG.

Contiguous leads simply means leads that are pertaining to the same anatomical region of the heart.

The following leads pertain to each region of the heart:

Anteroseptal: V1, V2
Anteroapical: V3, V4
Anterolateral: V5, V6
Lateral: I, aVL
Inferior: II, III, aVF

The precordial and lateral leads are often affected together as the area of infarction is not always exact.

As an example, the EKG below is an inferior wall STEMI:

Inferior wall MI with ST elevation in leads II, III, and aVF, with reciprocal changes in the lateral leads.

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Everything you need to know on how to read a rhythm strip!

ACUTE MANAGEMENT OF STEMI

STEMIs are true medical emergencies.

The patient is at a high risk of significant conduction disturbances and arrhythmias including cardiac arrest.

The longer you wait – the more heart cells will die, leading to worse cardiac outcomes as well as increasing the possibility of patient death.

A 12-lead ECG should be obtained within 10 minutes of any patient with significant cardiac symptoms including chest pain or SOB.

Women, older adults, and diabetics may have atypical presentations including a “silent” MI, where they don’t even have chest pain.

There are many actions that need to be taken in a short amount of time, and many medications that will need to be administered before the cath team gets there.

A code STEMI should be activated (or whatever your facility’s version of it is), so the interventional cardiologist and the cath team can be alerted ASAP.

The patient should be hooked up to the monitor, vital signs obtained, IV access x 2 should be established (preferably an 18g), labs drawn and sent including troponin and PT/PTT, and the defibrillation pads should be applied.

Any abnormal vital signs should be addressed, and any arrhythmias should be managed via ACLS guidelines.

Oxygen should be administered to maintain O2 >90%.

Aspirin 324mg should be chewed and swallowed. A rectal suppository of 300mg can be given if the patient cannot tolerate PO for some reason.

Antiplatelet therapy with P2y12 receptor blockers such as Plavix or Brilinta should be given in addition to the aspirin.

Nitroglycerin should be administered 0.4mg SL x 3 q5min if the patient has persistent chest discomfort, HTN, or signs of heart failure.

However, do not give if they have used phosphodiesterase inhibitors like Viagra or Cialis within the last 24h.

Don’t give Nitro if they have a low blood pressure, if they have severe aortic stenosis, or if there is a possibility of a right ventricular infarct (sometimes presents with inferior wall MIs). Nitro can cause severe hypotension in these patients.

For persistent symptoms, an IV nitro drip can be used.

Anticoagulants like an unfractionated heparin drip should be given. Other options include Lovenox.

If the patient has signs of left heart failure, treat with nitro as above, loop diuretic like Lasix, +/- Bipap.

Morphine 2-4mg slow IVP q5-15min can be given for persistent severe chest pain or anxiety. However, there is research indicating an increased risk of death when morphine is given in STEMI.

It is possible that morphine may interfere with the antiplatelet effect of P2y 12 receptor blockers. So morphine should be avoided unless absolutely required for pain control.

Atorvastatin 80mg PO should be given ASAP, preferably before PCI in those who are not already on a statin. If the patient on it already, their dose should be increased to 80mg.

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method and should happen ASAP.

This is when the interventional cardiologist will take the patient to the cardiac cath lab and perform angiography and stent placement to open up the occluded vessel.

Fibrinolytics can alternatively be given, specifically if there is no access to a cath lab within a reasonable time frame (120 min), as long as symptoms < 12 hours and no contraindications (i.e. risk of bleeding).

Beta-blockers are initiated within 24 hours, unless they are contraindicated such as with bradycardia, HF, or severe reactive airway disease. This can be started after PCI.

You may also like: “Adverse Drug Reactions Nurses Need to Know”

Non-ST Segment Elevation Myocardial Infarction (STEMI)

As the name suggests, an NSTEMI does not have ST elevation seen on the ECG, but it is still a heart attack.

An elevated and rising troponin level is associated with an NSTEMI.

The ECG can be completely normal, or it can have nonspecific T wave changes or even ST depression in contiguous leads.

Management of an NSTEMI is similar to a STEMI in terms of medications. However, they are not given fibrinolytic and are not emergently brought to the cath lab. They may or may not get a cardiac cath during their hospital stay.

Instead, medication therapy is maximized like the ones described above. The patient is continued to be monitored, and troponin levels are trended usually every 6-8 hours.

STEMIs and NSTEMIs are critical emergent events that nurses need to know well! You will be running into this at some point in your nursing career, and you want to know exactly what you’re doing when it happens! Being able to recognize a STEMI on the ECG is the first step!

References

Textbooks

ECGs Made Easy (6th ed.) <<< this is my favorite ECG PDF

Ekgs for the nurse practitioner and physician assistant

UpToDate

Overview of the acute management of ST-elevation myocardial infarction

ECG tutorial: Myocardial ischemia and infarction

Other

AHA ACLS Algorithms

Attributions

“Coronary Blood Vessels” by OpenStax College is licensed under CC BY 2.0, changes were made.

Want to learn more?

If you want to learn more, I have a complete video course “ECG Rhythm Master”, made specifically for nurses which goes into so much more depth and detail.

With this course you will be able to:

Identify all cardiac rhythms inside and out
Understand the pathophysiology of why and how arrhythmias occur
Learn how to manage arrhythmias like an expert nurse
Become proficient with emergency procedures like transcutaneous pacing, defibrillation, synchronized shock, and more!

I also include some great free bonuses with the course, including:

ECG Rhythm Guide eBook (190 pages!)
Code Cart Med Guide (code cart medication guide)
Code STEMI (recognizing STEMI on an EKG)

You can use the code “SPRING2021” for a limited time 15% discount, exclusive to my readers!

Check out more about the course here!

You may also like:

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

How to read an EKG Rhythm Strip - Pin Share

Vagal Maneuvers: How to Stop your Patient’s SVT

Mar 15, 2021 | 0 comments

Vagal Maneuvers: How to Stop your Patient’s SVT

Vagal maneuvers are used in the clinical setting to slow down fast heart rates – primarily for supraventricular tachycardia (SVT) and sometimes rapid atrial fibrillation (AF RVR).

There are numerous physical maneuvers that can slow down the heart rate – and there is an important modified technique which can almost triple your chances of success!

Svt and Vagal Maneuvers

Supraventricular Tachycardia (SVT) is a very rapid regularly arrhythmia caused by a reentrant loop within the heart.

Essentially – the signal goes around and around in a circuit, producing very fast heart rates.

While SVT is an umbrella term for any tachycardia originating above the ventricles of the heart, it usually is used in reference to AV Nodal Reentrant Tachycardia (AVNRT). This arrhythmia is due to a reentrant loop within/near the AV node itself.

Some patients have abnormal conduction tissue in this area, and if a premature beat comes at the wrong time – it can throw them into this very fast heart rhythm.

This condition occurs more often in younger patients, females, and can be secondary to certain triggers like exercise, stimulants, or even alcohol.

Patients will usually be symptomatic and feel palpitations, fatigue, or dizziness. They can also have chest pain, SOB, or syncope.

Remember when the heart is beating this fast, the cardiac chamber’s ability to fill is decreased, and cardiac output can suffer – leading to symptoms.

When a patient comes in with SVT, their heart rate is usually very fast, with rates often between 150-200 bpm.

We want to stop or “break” this rhythm as soon as possible, so the patient does not decompensate.

If we look at the Adult tachycardia ACLS algorithm, we can see that the first thing we do to attempt to stop the SVT in a stable patient is vagal maneuvers.

The Vagus nerve and the Heart

In order to understand vagal maneuvers, you first need to understand how the vagus nerve works.

The vagus nerve is the primary method that the parasympathetic nervous system affects the body.

This is the 10th cranial nerve which travels from your brain throughout the body. This is how the brain controls certain automatic functions.

When the vagus nerve is activated, the following effects on the body occur:

Bronchial constriction
Pupillary constriction
Increased blood flow to the stomach’
Increased digestion

Remember – “rest and digest”

Regarding the heart, the vagus nerve also has important physiological effects on the cardiac system. These include:

Slowing of the heart rate
Slowing of the conduction velocity of the AV node
Decreases the strength of contractions

As you can see, stimulation of the vagal nerve can be utilized to slow the conduction and increase the refractory period of the AV node which hopefully breaks the SVT reentrant loop, leading to conversion back to normal sinus rhythm (NSR).

There are various physical maneuvers that can stimulate the vagus nerve – and many you may do without trying. These include:

Coughing
Vomiting
Cold water immersion

Then there are certain physical maneuvers termed “vagal maneuvers” that we can perform in the hospital to intentionally cause vagal response and hopefully slow down a tachyarrhythmia such as with SVT.

These maneuvers include the Valsalva maneuver and the carotid sinus massage.

But did you know that by modifying the Valsalva maneuver – you can almost triple your chances of success?

Get my ECG Cheat Sheets!

Everything you need to know on how to read a rhythm strip!

The Modified Valsalva Maneuver

The Valsalva maneuver is the classic vagal maneuver used to stimulate the vagus nerve and stop SVT.

This is used on patients who are stable (stable vital signs) and can follow commands.

To perform the Valsalva maneuver, the patient intentionally “bears down” or strains for 10-15 seconds.

This has a 17% success rate in converting SVT. However, by modifying the Valsalva maneuver we can almost triple this success rate!

The Modified valsalva or the positional valsalva maneuver has a significantly higher success rate of 43%!

That’s almost half of your patients with SVT who this can convert back to NSR without any additional medications or interventions.

To perform the modified Valsalva maneuver:

Have a Physician or APP at the bedside
Place the patient in a semi-recumbent position (45° Semi-fowlers)
Have the patient take a normal breath in
Have them forcefully exhale with a closed glottis (bearing down) for 15 seconds
Immediately place them supine and raise their legs to 45 degrees for 15 seconds
Return to semi-fowlers position and watch for up to 1 minute for resolution of the SVT

Clinical Tip: If the patient has trouble bearing down, you can place an empty 10-mL syringe in their mouth and have them blow hard enough to see the plunger move.

As you can see, this technique requires a few assistants, but it is clearly the better option when attempting to convert SVT with vagal maneuvers.

The Carotid Sinus Massage

The carotid sinus massage is a vagal maneuver that you can perform on someone who cannot follow commands.

The carotid sinus is an area located just below the internal carotid artery at the level of the thyroid cartilage, near the pulse.

This area is very sensitive to mechanical pressure, and mechanical pressure to this area can stimulate the vagus nerve.

To perform the carotid sinus massage:

Place the patient supine with their neck extended toward the opposite side
Ensure there is no carotid bruit with your stethoscope
Locate the carotid sinus. This is inferior to the angle of the mandible at the level of the thyroid cartilage near the pulse
Apply firm pressure for 5-10 seconds
You can repeat on the other side if needed

The carotid sinus should never be performed in the following circumstances:

Without a physician / APP at the bedside
On both sides simultaneously
In someone with TIA or stroke within the last 3 months
In someone with known carotid stenosis or active carotid bruit

Complications of Vagal Maneuvers

Any side effects from vagal maneuvers are usually short-lived and an “over-exaggeration” of expected effects.

These include sinus pauses, brief asystole, bradycardia, AV blocks and hypotension.

These will usually fix themselves within seconds to minutes.

Strokes are a major concern with the carotid sinus massage and can happen in <1% of patients.

This is why those with potential carotid stenosis or recent history of strokes should not have the carotid sinus massage.

References:

Aehlert, B. J. (2017). ECGs made easy (6th ed.). Elsevier Health Sciences.

Burns, E. (2019). Supraventricular tachycardia. In ECG Library. Retrieved from https://litfl.com/supraventricular-tachycardia-svt-ecg-library/

Frisch, D. R., Zimetbaum, P. J. (2020). Vagal maneuvers. In UpToDate. Retrieved from https://www.uptodate.com/contents/vagal-maneuvers

Grauer, K., MD. (2014). ECG Pocket Brain: Expanded Version (6th ed., pp. 65-68). Gainesville, FL: KG/EKG Press.

Knight, B. P. (2020). Atrioventricular nodal reentrant tachycardia. In UpToDate. Retrieved from https://www.uptodate.com/contents/atrioventricular-nodal-reentrant-tachycardia

Tintinalli, J. E., Brady, W. J., Laughrey, T. S., & Ghaemmaghami, C. A. (2016). Cardiac Rhythm Disturbances. In Tintinalli’s emergency medicine: A comprehensive study guide (8th ed., pp. 126). McGraw-Hill Education.

Want to Learn More?

If you want to learn more about vagal maneuvers, SVT, and every other cardiac arrhythmia – check out my ECG Rhythm online video course out now!

It’s specifically designed for nurses, and not only teaches you how to identify each arrhythmia, but also why and how they occur, and what to do about it!

If you’re not ready to take that leap yet but still want to learn more about ECG rhythms – be sure to download my free ECG Cheat Sheet below!

You may also like:

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

5 Appendicitis Signs you Don’t Want to Miss!

Feb 10, 2021 | 0 comments

5 Appendicitis Signs you Don’t Want to Miss!

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Knowing Appendicitis signs is super important for nurses and medical professionals.

Appendicitis is the number one cause for abdominal pain needing emergent surgery. Missing appendicitis can lead to worsened outcomes including sepsis, perforation, longer hospital stays, and an increased chance of death.

The Appendix and Appendicitis Signs

The appendix is a small appendage at the beginning of the large intestine which stems off of the cecum.

The actual function of the appendix is unknown, although there are some theories that it assists with maintaining healthy gut bacteria as well as with the immune system.

The appendix can become blocked and inflamed which leads to appendicitis, which is inflammation of the appendix.This is usually blocked by a small piece of feces that occludes the appendix, termed a fecalith.

The appendix can also be blocked by stones, lymphoid tissue, infections, and even cancer.

This blocked appendix eventually develops bacterial overgrowth, ischemia, and possibly can even perforate the bowel. It can cause sepsis and severe infection.

Many cases of appendicitis happen between the ages of 10-30. While common in children, it also occurs in young adults and sometimes even older individuals.

Abdominal pain is very common, and sometimes it can be difficult to tell what is causing it because there are so many potential causes of abdominal pain.

Pain in the abdominal doesn’t always present where you would expect as well. There are specific physical exam appendicitis signs which can be used to raise the suspicion of appendicitis.

Appendicitis Symptoms

A patient who presents with appendicitis will often complain of the following appendicitis symptoms:

General malaise, indigestion, or change in bowel habits
Vague abdominal pain, usually near the umbilicus, which eventually migrates toward right lower quadrant (RLQ)
Nausea and/or vomiting
Fever

There are other symptoms as well, but these are the most common. As you can see – these are not super specific aside from the location of the pain which can be a late sign.

Up to 33% of patients can have retrocecal or pelvic appendix which can cause right flank pain or pelvic pain instead of the typical RLQ pain. This is why it is so important to know not only appendicitis symptoms but also appendicitis signs.

The physical exam is super important when evaluating abdominal pain. There are multiple physical exam maneuvers that you can do as the nurse or APP to detect appendicitis signs and further guide the need for imaging.

Related Article: 5 Advanced Physical Exam Maneuvers

1. Mcburney’s Sign

The first appendicitis sign to know is Mcburney’s sign. This is the bread and butter of recognizing appendicitis.

Mcburney’s sign, also known as Mcburney’s point tenderness is when the patient’s most tender area is 1.5-2 inches from the anterior superior iliac spine in the direction of the umbilicus. Ok… so where exactly is that?

Draw an imaginary line from the anterior superior iliac spine to the naval, and approximately 1/3 down the line closer to the iliac spine is Mcburney’s point.

If you press generally in the RLQ and they are tender, appendicitis should be high up in your differential.

If a patient has abdominal pain with this being their most tender area, they should undergo further testing to rule out acute appendicitis.

Mcburney’s sign is 50-94% sensitive, and 75-86% specific for appendicitis. This means if the pain is specific to this location, it very well could be appendicits.

Other causes of RLQ tenderness include kidney stones, ovarian cysts or torsion, ectopic pregnancy, testicular torsion, abdominal wall strain, or some other type of abdominal condition.

2. Guarding and Rebound Tenderness

Guarding is when a patient involuntarily tenses their abdominal muscles when you palpate.

Rebound tenderness is when the pain temporarily worsens when you suddenly release pressure.

While these aren’t specific appendicitis signs, they indicate potential peritonitis which is inflammation of the inside of the abdominal wall cavity.

Causes of peritonitis include ruptured appendicitis, perforated bowel in another area like with perforated diverticulitis, or direct infection through trauma or with peritoneal dialysis.

Any guarding or rebound with abdominal pain should raise suspicion for serious pathology, and CT imaging should be highly considered.

Bottom line – if the patient is tender in the RLQ and they are guarding and have rebound tenderness – this is highly suspicious for acute ruptured appendicitis.

Related Article: 6 Steps for Sepsis Management

3. Rovsing’s Sign

Rovsing’s sign is when you palpate the left lower quadrant and the patient is tender in the right lower quadrant (RLQ) area.

This indicates local peritoneal irritation. This is also called indirect tenderness.

This appendicitis sign is only 22-68% sensitive, and 58-96% specific. This means it’s not always going to be present with appendicitis, but if it is there – you should be ruling appendicitis out.

4. Psoas Sign

Psoas sign is when the patient lies supine and attempts to flex their hip against resistance. Place your hand on their thigh and ask them to lift their leg. If they have pain in the RLQ – this is a positive Psoas sign.

Alternatively, you can lie them on their left side and passively extend their right hip behind them. If this causes pain in the RLQ – this is also a positive Psoas sign.

This appendicitis sign checks for irritation of the iliopsoas muscle. This because the iliopsoas muscle lies in close proximity to the appendix.

The Psoas sign tends to correlate more with retrocecal appendicitis. This is when the appendage is in the direction of the colon behind the cecum, which can present in up to 33% of cases.

5. Obturator Sign

The Obturator Sign is when the patient is lying supine, and you passively flex their hip and knee, and then internally rotate. If this causes pain in the RLQ – this is a positive obturator sign.

Sometimes the appendix lies in close proximity to the right obturator internus muscle. This specific sign is associated with a pelvic appendix when the appendix tip migrates in the direction of the pelvis.

Appendicitis Management

After using these appendicitis signs into your physical exam, you should have a pretty good idea of how suspicious you are of appendicitis.

The next steps usually involve abdominal imaging.

In children and sometimes pregnant women, this can be a RLQ ultrasound. However, in most adults, this involves a CT abdomen/pelvis with contrast.

The CT abdomen/pelvis is the preferred test for appendicitis and has the highest sensitivity. This is recommended to be done with IV contrast, with or without PO contrast. If the patient has a BMI <25, it is a good idea to use PO contrast to enhance visualization of the appendix. The use of PO contrast is often facility dependent.

CT abdomen/pelvis is also great because it can give you possible alternative causes of abdominal pain. The downside is the obvious radiation exposure.

Once appendicitis is diagnosed, antibiotics should be started and surgery should be consulted emergently.

Antibiotics for acute appendicitis include:

Zosyn
Flagyl + Ceftriaxone or Cefepime
Ertapenem

For a full list, please look out the EMRA app. or read about the management here on UpToDate

Ultimately, the patient will likely need emergent surgery to remove the appendix, although rarely it can be just managed medically with antibiotics.

Don’t forget about these essential appendicitis signs to incorporate into your physical exam of your patient!

Also check out:

REFERENCES

Textbooks:

Bates Guide to Physical Examination

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide

UpToDate:

Acute appendicitis in adults: Clinical manifestations and differential diagnosis

Evaluation of the adult with abdominal pain

Management of acute appendicitis in adults

Other Sources / Apps:

Appendicitis (Wikem)

EMRA Antibiotic Guid‪e

Patient Care Organization Sheets

Great for bedside RNs!

Use these FREE patient care organization sheets to keep your patient information nice and organized. What do you have to lose - it's absolutely FREE!

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

21+ mRNA Vaccine Questions Answered for Nurses

Jan 27, 2021 | 2 comments

21+ mRNA Vaccine Questions Answered for Nurses

Last updated: January 27, 2021

The new mRNA vaccines for COVID are being distributed, and as a nurse, it is important to know these vaccines, how they work, and their safety data!

Our patients respect our medical opinion, and we need to give accurate information so they can make an informed decision.

This article mainly focuses on the mRNA vaccines (Pfizer and Moderna), as they are currently the vaccines being distributed as they have obtained FDA emergency use authorization.

With these vaccines being so new – it leaves many wondering, “is it’s safe?”

I’m going to go over what the data tells us and hopefully give you enough insight into making an informed decision, and help your patients do the same!

Quick Note: I want to preface this article by first stating that I am a nurse practitioner and I see many COVID patients on the frontlines in the ED. I am not, however, an epidemiologist or scientist who works directly with COVID in a lab, so I am simply basing my own opinions on what the data says, as well as my understanding of the virus by seeing it firsthand.

1. How do mRNA Vaccines Work?

Vaccines generally work by introducing a dead or weakened virus, or part of a virus into your bloodstream via an Intramuscular or subcutaneous injection.

This creates an immune response that helps your body be able to attack the real virus whenever it comes into contact with it in the future. Typical vaccines include those with:

A live but weakened or “attenuated” virus, which leads to a better immune response, but can actually cause the disease in very few people – mainly those who are immunocompromised.
A dead or “inactivated” virus, in which the virus has been inactivated and is unable to replicate and cause disease. This doesn’t create as good of an immune response so it may need multiple doses or boosters. An example of this is the flu shot or hepatitis A.
Those that contain a piece of the virus, like part of its specific protein. This also cannot replicate or cause disease. Examples include hep B, meningitis, and HPV.
There’s also some vaccines that contain a toxoid that the virus creates, such as tetanus or diphtheria, like the Tdap vaccine.

The mRNA Vaccines (Pfizer and Moderna) actually do not inject the virus or any of it’s parts into you.

Instead, it contains mRNA which codes for the COVID spike protein – a protein specifically found on the COVID virus.

RNA is a single-stranded molecule that normally takes information from your DNA in the nucleus of the cell, and brings it to the ribosome of the cell to create proteins which basically keep the cell running and functioning appropriately.

So what scientists at Pfizer and Moderna have done is isolated the genome sequence of the mRNA which codes for the spike protein in the coronavirus, as this protein is not naturally found within your body. So what does the body do with this mRNA?

The mRNA is absorbed into your cells and carried to your ribosome where it is used as instructions to create the spike protein of COVID.

This protein cannot lead to disease, but it should lead to an immune response. Your body sees this foreign entity and creates antibodies to kill it and any future proteins it detects.

If the actual COVID virus now enters your body, your body should be able to detect it, and your immune system will target the cell and destroy it before it has a chance to replicate enough to cause disease and hopefully prevent you from spreading it.

2. Are mRNA Vaccines Safe?

This isn’t an easy question since it is so new, but so far it seems to be very safe and effective.

While mRNA vaccines have not actually been used in the US, researchers have been studying them for decades and have tested them on humans before for viruses like rabies, flu, CMV, and Zika.

In order to test the safety and efficacy of these new vaccines, clinical trials were conducted.

Pfizer and Moderna injected this vaccine into willing people and followed them for any adverse side effects, as well as those who ended up getting symptomatic COVID or severe disease.

Over 30,000 people were enrolled in the Moderna trial and over 40,000 people in the Pfizer trial.

Those who got the Pfizer vaccine get 2 injections, 21 days apart. Those who got the Moderna vaccine get 2 injections, 28 days apart.

Pfizer was tested on people 16 years and older, and Moderna was tested on adults 18 years and older.

Long story short – what they found was that most symptomatic covid cases were occurring in the placebo groups, which means those who did not receive the vaccine. Severe cases of COVID almost exclusively occurred in the placebo group!

The Pfizer vaccine boasts 95% efficacy beginning 1 week after the second dose, and Moderna boasts 94.1% efficacy 2 weeks after the second dose.

Both mRNA vaccines essentially use the same mRNA, basically the same ingredients, and both had very similar findings in their trials. This in and of itself is reassuring and offers an element of reproducibility.

The data from these trials are overall VERY reassuring. You can read more about the Pfizer or Moderna trials to get more information!

3. What Side Effects Can be Expected?

Common side effects include local injection site pain, headache, and fatigue. These vaccines should not cause COVID symptoms such as cough or SOB. It is impossible for these vaccines to cause actual COVID disease.

These vague side effects are common and expected when getting a vaccination, and are often an indication of the body’s immune response. They are short-lived and not severe.

Symptoms after the first injection tend to be less severe, and symptoms after the second injection were more significant – although both were very short lived (1-2 days).

Anecdotal Note: I have received both injections from the Moderna Vaccine. After the first shot, I had arm soreness which was worse than a typical vaccine, but resolved over 1-2 days. The day after my second injection, I had body aches and fatigue which resolved by the next day.

These symptoms seem common based on my colleagues experiences as well. Those who had symptomatic COVID anecdotally reported worsened symptoms after the first dose, although still short-lived.

Are all side effects mild and short-lived? We’ll dive more into that in future questions!

4. Can the mRNA Vaccines cause Anaphylaxis?

Just like any medication or vaccine, allergic reactions can occur.

Anaphylactic reactions have occurred after COVID vaccine administration, although not common, and seem to mainly occur in those with a history of severe allergies.

Overall it seems to be very rare – 11 people per million. Regardless, we know how to treat anaphylaxis and allergic reactions very well – Benadryl, Solumedrol, and Pepcid!

The CDC recommends those without a history of anaphylaxis to wait 15 minutes after their injection for monitoring, and those with a history of anaphylaxis to wait 30 minutes – just to be on the safe side.

5. Can the mRNA Vaccines cause Facial Paralysis?

Bell’s palsy is unilateral facial paralysis that can occur, which is usually temporary.

In the COVID vaccine trials, there were 7 reported cases of Bell’s palsy, in the over 70,000 participants in Pfizer/Moderna’s clinical trials.

While there were slightly more cases in the vaccine groups than the placebo groups, this rate is consistent with bell’s palsy rates in the general public, so likely not statistically significant.

However, some viruses and vaccines have been associated with bell’s palsy in the past, although rare.

Even if there is a small rare chance of the COVID vaccine causing Bell’s Palsy – it is usually temporary and treatable, and the benefits outweigh the risks.

6. Can the mRNA Vaccines cause COVID?

No – it is physiologically impossible for it to cause COVID disease.

Vaccines that contain live “weakened” viruses do have the capacity to cause disease in those who are immunocompromised – an example being the MMR vaccine.

However, those with only pieces of the virus or mRNA that code for pieces of the virus cannot cause COVID. So mRNA Vaccines cannot cause COVID illness.

7. Will these Vaccines cause False Positive Results on Testing?

No, the vaccine should not alter PCR or antigen testing. Test swabs collect viral particles and test for their genetic code. These swabs are collected from areas where you are expressing the virus, like the nasopharynx.

While the mRNA causes your cells to produce the COVID spike protein, they are not expressed or spread outside of your body.

The PCR and antigen tests check for active infection and do not check for antibodies. The vaccine should not alter these test results.

8. Do the Vaccines Change your DNA?

No. Only specific viruses can alter your DNA. These viruses are called retroviruses and require a specific protein called reverse transcriptase.

The mRNA in the COVID vaccines do not alter your DNA in any way.

9. Do the Vaccines Contain a Microchip?

No – this is nonsense and I’m not really sure what else to say about it.

10. Do the mRNA Vaccines cause Infertility Issues?

There is no convincing evidence to suggest that the mRNA vaccines cause infertility.

This idea was picked up and used by anti-vax propaganda. This myth started when a German Epidemiologist and a former Pfizer employee asked the FDA to not grant authorization to use the vaccine.

They said that the COVID vaccine’s mRNA is similar to the syncytin-1 protein which is used in mammals to help create placenta during pregnancy.

While the proteins do share a minimal amount of similar code, the scientist and medical community at large reject the notion that it could cause infertility.

While it is still so new – it cannot be said with certainty because we don’t have the data. However, 23 women did conceive during these trials, and they are still being followed.

11. Can Pregnant Patients Get an mRNA Vaccine?

This is a decision that should be discussed with the patient’s OBGYN, and they can come to a decision together.

The clinical trials did not study vaccination in pregnant mothers, so we don’t have specific data regarding pregnant individuals. There were some animal studies that looked promising.

The American College of Obstetricians and Gynecologists (ACOG) recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet the criteria for vaccination based on priority groups.

This means it is likely a good idea for pregnant mothers who are at an increased risk of getting COVID to get the mRNA vaccine.

What we do know is that pregnant mothers are at increased risk from side effects and complications if they get COVID.

They are more likely to be hospitalized, placed in the ICU, ventilated, and die than if they weren’t pregnant.

12. Can Breastfeeding Mothers get the Vaccine?

Again – this decision should be made with the patient’s OBGYN and Pediatrician.

There is just not enough data studying this to make a sweeping recommendation.

It is unlikely that the vaccines would be unsafe for the baby, and there is a possibility of passing on some passive immunity obtained from the vaccine to a breastfeeding infant.

13. Can those with Autoimmune Diseases get the Vaccine?

While there doesn’t appear to be any specific contraindications, this is something that should be discussed with the patient’s physician / Rheumatologist.

The risks of getting symptomatic COVID may be worse than the risks of getting the COVID vaccine.

14. Should Patients who had Symptomatic COVID get the Vaccine?

The idea is that if you had symptomatic COVID – you should have natural antibodies already for the virus – so why get the vaccine?

This is a decision you have to decide on with your Provider. It likely won’t hurt and could help, so the CDC is in favor or those who had COVID to also get vaccinated.

While it may be recommended to wait 90 days after symptomatic covid for the infection, this is not a rule and there is no specific timeline established.

This is more to allow those who have not built any immunity to receive the vaccine first.

You should get the vaccine after you recover from symptomatic COVID and when you feel it is appropriate.

15. What if you or your Patient doesn’t get the Vaccine?

As of today COVID has killed over 400,000 people in the US and 2.15 million people worldwide. This number is rising very quickly.

Even if COVID doesn’t kill you or your patients, it can cause many long-lasting side effects.

During an active COVID infection, it can cause multifocal pneumonia and respiratory failure leading to hospitalization, ventilation, and possibly death.

Severe COVID can also cause blood clots leading to pulmonary embolisms and embolic strokes.

It can cause inflammation of your brain and heart as well, leading to irreversible damage in some cases.

There have been observational studies done which show that up to one-third of patients who had symptomatic COVID had persistent symptoms after resolution of the virus. These include:

Fatigue
Dyspnea (Shortness of breath)
Chest Pain
Cough
Anosmia (loss of smell)
Ageusia (loss of taste)
More (joint pains, headaches, myalgias, etc)

There may still be other long-term side effects that we still don’t know about.

So what’s riskier? Getting a vaccine that seems to be very safe and doesn’t seem to have any serious long-lasting side effects, or take your chances with getting COVID?

I can’t make that decision for you or your patients.

But if you do decide to get the vaccine, what can you expect?

16. If you get the Vaccine, What can you Expect?

You can expect to get 2 injections, 21 days apart with Pfizer or 28 days apart with Moderna.

The full efficacy seems to be established about 1-2 weeks after the second injection, depending on the vaccine (1 week after Pfizer, 2 weeks after Moderna).

These were the timelines studied in the clinical trials.

17. Can I Stop Wearing Masks and Social Distancing once I’m Vaccinated?

Well – no, not immediately.

Remember that even a 94-95% efficacy still leaves that 5-6% of people who will still get symptomatic COVID.

These people will likely be contagious, and they still could get severe COVID and have to be hospitalized or worse.

Secondly, both Pfizer and Moderna require 2 shots before full efficacy is expected. The body takes time to build up an antibody response. It can take 1-2 weeks after the second dose for full efficacy.

Additionally, it has not been proven by evidence that these vaccines prevent you from spreading COVID. The trials only prove that they are 94-95% effective at reducing symptomatic COVID.

That’s right. Even if you don’t get symptomatic COVID – you could possibly spread it.

18. Could you get the COVID vaccine and be an Asymptomatic Spreader?

Theoretically, it is unlikely that you will be spreading the virus after vaccination.

Hopefully, your body has created an immune response and antibodies which will attack COVID before it can replicate and cause disease or be contagious.

HOWEVER – we don’t have the data to back this up, and there another important consideration – Mucosal Immunity.

We don’t know how well the antibodies penetrate the nasal mucosa. There is a possibility that the virus can still replicate in the mucosa of your nasopharynx.

While it may not cause symptomatic disease since you should have circulating antibodies – you might still spread it to others when coughing, sneezing, or even breathing.

This is something that we should have more data on soon.

This is why it is imperative to continue to wash our hands, wear our masks, and practice social distancing.

19. When will Herd Immunity be Established?

It is going to take some time for the majority of the US to become vaccinated.

This means we need about 70%+ of the population to be vaccinated or infected before some type of herd immunity can be expected and established.

Herd immunity occurs at different percentages of vaccinated/infected individuals based on each specific virus.

This number is unknown for COVID, but experts say at least 70% need to be vaccinated and/or infected for some type of herd immunity to protect us.

It is unlikely that mask mandates and social distancing will become a “thing of the past” until we get to this point.

20. Will the mRNA Vaccines Cover the New Strains?

Unfortunately, there are multiple mutated strains or variants popping up in the UK, Africa, and other places.

These strains are spreading fast as they are more contagious (30-70% more transmissible).

However, these don’t necessarily seem to be more deadly. However, with surges in COVID cases and hospitalizations, increased deaths could occur due to the burden put on the healthcare system.

As far as we know, these vaccines should be effective against these mutated variants.

However, preliminary data does suggest that the vaccines may not work as well against the South African variant! Just in case, Moderna has already begun production on a “booster shot” which would specifically target these variants.

21. How Long will Immunity Last from these mRNA Vaccines?

As mentioned above – complete immunity is not guaranteed.

However, if antibodies are created, it is unknown how long they will last.

What we do know is that immunity wanes over time. Those who get symptomatic illness tend to build a better immune response than those who get vaccinations.

Many patients who had symptomatic COVID in early 2020 still have antibodies – this is good news!

We don’t know how long immunity will last, and we don’t know how much further mutations will alter the effectiveness of the immunity.

22. Are there other Vaccines Available?

Pfizer and Moderna are mRNA vaccines which have already obtained emergency use authorization (EUA) from the FDA.

There are two other vaccines that may obtain approval as well. These are not mRNA vaccines. They include:

Johnson & Johnson, which uses adenovirus to carry genetic material for COVID
AstraZeneca, which uses a chimpanzee adenovirus to do this

These do not appear to be as effective as the mRNA vaccines, but may still prove helpful, and we must continue to follow the data.

Production and distribution of the mRNA vaccines will prove tough, and additional effective vaccines will be helpful!

So Should you or your Patient get the Vaccine?

That’s for you to decide, based on the data and taking into account what your physician or healthcare provider recommends.

Additionally, it is for your patients to decide based on informed consent.

It is not your job to judge them or tell them what to do. All you can do is offer evidence-based recommendations and up to date information, and allow them to make that decision for themselves.

You can also lead by example and get the vaccine for yourself, trusting the science and once again being that hero that we were once called in the beginning of this pandemic.

I think frontline workers and those with a high risk should seriously consider getting vaccinated.

As far as everyone else – that’ a decision you (or they) have to make, but the data looks promising and this could be our chance at returning to a state of semi-normalcy.

Note: If you want more information – you should follow Dr. Kat the Epidemiologist on TikTok! She creates great content backed in science on all things COVID and mRNA Vaccines!

I got my vaccine! Did you? Why or why not? Let us know in the comments below!

You might like: “These 8 COVID nursing tips could save your life”

References:

Pfizer / Moderna Studies:

Moderna Announces Primary Efficacy Analysis in Phase 3 COVE Study for Its COVID-19 Vaccine Candidate and Filing Today with U.S. FDA for Emergency Use Authorization

PFIZER AND BIONTECH CONCLUDE PHASE 3 STUDY OF COVID-19 VACCINE CANDIDATE, MEETING ALL PRIMARY EFFICACY ENDPOINTS

Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine (Pfizer)

Safety and Immunogenicity of SARS-CoV-2 mRNA-1273 Vaccine in Older Adults (Moderna)

Vaccine Info:

Coronavirus disease 2019 (COVID-19): Vaccines to prevent SARS-CoV-2 infection (UTD)

Facts about COVID-19 Vaccines (CDC)

Understanding mRNA COVID-19 Vaccines (CDC)

Vaccine Types

Anaphylaxis:

Allergic Reactions Including Anaphylaxis After Receipt of the First Dose of Pfizer-BioNTech COVID-19 Vaccine

Interim Considerations: Preparing for the Potential Management of Anaphylaxis After COVID-19 Vaccination

Bell’s Palsy:

FDA: Track Vaccine Recipients for Facial Paralysis

Pregnancy & Breastfeeding:

COVID-19 Vaccines and Pregnancy: Conversation Guide for Clinicians (ACOG)

Vaccination Considerations for People who are Pregnant or Breastfeeding (CDC)

Why COVID Vaccines are Falsely Linked to Infertility

Persistent COVID:

Coronavirus disease 2019 (COVID-19): Evaluation and management of adults following acute viral illness (UTD)

COVID Cheat Sheet

Everything you need to know about treating COVID pneumonia in the ER and Inpatient setting!

William Kelly, MSN, FNP-C( Author )

I am an ER Nurse Practitioner who creates content for bedside nurses and clinicians, making practical application of nursing education. Read more!

HealthAndWillness.org

Adverse Drug Reactions Nurses NEED to know

Dec 28, 2020 | 2 comments

Adverse Drug Reactions Nurses NEED to know

Medications are a huge part of modern medicine and how we treat disease, but there are many adverse drug reactions that can occur.

As nurses, it is important to educate our patients about these adverse drug reactions, what to expect, and what to do if they are experienced by our patients.

Some of these medication reactions are ingrained in us, but others are less commonly taught.

Make sure you remember to educate your patients who are being prescribed these medications!

Antibiotics and Adverse Drug Reactions

Antibiotics are essential in treating bacterial disease, but they don’t come without their own side effects!

There are many different classes of antibiotics. Because of this, some adverse drug reactions apply to only certain antibiotics, and some apply to antibiotics as a whole.

1. Diarrhea and Antibiotics

All antibiotics can cause diarrhea. This is due to normal “good” bacteria in your intestines being killed by the antibiotic, leading to imbalances digestion.

While all antibiotics can cause diarrhea, there are certain antibiotics that are more likely to cause diarrhea.

These include amoxicillin, cephalosporins, clindamycin. When mixed with clavulanic acid, diarrhea tends to be more pronounced (i.e. Augmentin).

Clostridium Difficicile (CDIFF) is an opportunistic diarrheal infection that can lead to profuse diarrhea and can be difficult to treat.

Antibiotics increase the risk of CDIFF – especially broad-spectrum antibiotics like cephalosporins, fluoroquinolones, and clindamycin.

Patient Education Example: “Some watery diarrhea and mild cramping can be expected while on antibiotics. Make sure to stay hydrated if this occurs. If you have excessive diarrhea, severe abdominal pain, abdominal swelling, fever, or blood or pus in your diarrhea – you should contact your doctor or return to the emergency department”.

2. Allergic Reactions

All medications and antibiotics can cause allergic reactions.

True allergic reactions cause itchy hives and potentially swelling of the face, eyes, lips, or mouth. It can even cause swelling of the airways and lead to wheezing and stridor.

When giving any prescribed medications, the patient should always be educated on the potential signs of an allergic reaction.

Patient Education Example: “All new medications can cause allergic reactions, and mild-moderate allergic reactions are common with antibiotics. If you develop a red, raised, itchy rash, immediately stop taking the antibiotic and call your doctor. If you develop swelling of the face, eyes, lips, tongue, or shortness of breath – this is potentially a life-threatening severe allergic reaction called anaphylaxis, and you should seek immediate medical care or call 911.”

3. Rifampin and Birth Control

Antibiotics were frequently thought to interact with birth control… but this is somewhat of a myth.

There is no convincing evidence that any antibiotic other than Rifampin interacts with birth control.

Rifampin is not a commonly prescribed antibiotic but is the recommended treatment for tuberculosis.

There is a concern that antibiotics as a whole can affect the gut microbiome which may alter estrogen levels, but this has not been proven and is likely untrue.

If patients are prescribed rifampin, they should be educated to use backup protection for up to 1 month after they finish the rifampin.

Patient Education Example: “While commonly believed to interact with birth control, there’s no evidence that most antibiotics do. If you want to be safe, you can use a backup method like condoms while taking the antibiotic, and up to a few days to a month after you finish.”

4. Doxycycline and GI Upset

Doxycycline is commonly given for infections including cellulitis, URIs, tick-borne illnesses, pneumonia, STDS, and more.

Doxycycline works great, but it does have some significant adverse drug reactions that we need to educate our patients about.

Doxycycline can cause some significant GI upset, including nausea, vomiting, and diarrhea.

Educating the patient to take this pill with food or milk can help, although it may inhibit some absorption of the drug.

Doxycycline (and clindamycin) can cause drug-induced esophagitis which can lead to significant inflammation and pain within the esophagus.

To prevent this, educate the patient to take Doxycycline with a full glass of water, milk, or eat food afterward, and stay upright for 30 minutes after taking it.

Patient Education Example: “Doxycycline can cause significant nausea and vomiting, and drinking milk or eating food directly after taking it can help minimize this. If not, drink with a full glass of water and remain upright for 30 minutes afterwards to prevent any damage to your esophagus.”

5. Flagyl and ETOH

Metronidazole, or Flagyl, or is commonly given for intestinal infections like colitis or diverticulitis, and for vaginal infections like trichomoniasis.

Flagyl is traditionally taught to NEVER be taken with alcohol as this can cause a “disulfiram-like reaction”.

Disulfiram causes excessive nausea, vomiting, and other unpleasant symptoms when mixed with alcohol.

Evidence of this severe reaction occurring with Flagyl is somewhat lacking, but it can sometimes occur. Educate the patient on this potential reaction, but if they do drink they may be fine.

It is never a bad idea to recommend against taking medications with alcohol.

Patient Education Example: “Flagyl can potentially cause nausea and vomiting if taken with alcohol. Avoid any alcohol consumption while taking it”.

6. Fluoroquinolones and Tendon Rupture

Fluoroquinolones are a powerful class of antibiotic which kill a broad-spectrum of bacteria.

These are commonly utilized to treat UTIs, Abdominal infections, and Pneumonia.

Fluoroquinolones have fallen out of favor recently due to their large number of potential side effects, even if rare.

These side effects include:

Hyper/hypoglycemia
Peripheral neuropathy
CNS effects (seizures, increased ICP, tremors)
Psych reactions (psychosis, hallucinations, deririum, etc)
Aortic aneurysm and dissection
Tendonitis and tendon rupture.

Sometimes these antibiotics are still needed, so be sure to educate the patient on these possible side effects.

The tendinopathy can occur hours or days after starting the antibiotic or sometimes delayed for months.

This is more likely to occur in those >60 years old, those on steroids, with diabetes or kidney failure, or with extended therapy.

Patient Education Example: “Cipro can rarely cause significant side effects like inflammation and even rupture of your tendons, most commonly the Achilles tendon above your heel. If you feel any swelling or pain in this area or near another joint, immediately stop taking and contact your doctor”.

Non-Antibiotics and Adverse Drug Reactions

Antibiotics are not the only cause for adverse drug reactions, and every medication has expected side effects.

While there are many potential adverse effects for every single medication, there are a few common or interesting side effects you should know to educate your patients on!

7. Dexamethasone and the Burning Crusade

Dexamethasone is a steroid given for various reasons, including sore throats, cerebral edema, migraines, and various other conditions in and out of the hospital.

Dexamethasone is commonly ordered IV in the ED and hospital. One interesting side effect that you need to warn your patients about perineal discomfort when given IV.

When given rapidly, perineal discomfort (burning or tingling) can occur.

I’ve personally heard “MY CROTCH IS ON FIRE!”.

This is usually short-lived but can cause significant discomfort and be shocking for the patient if not warned.

Dilute the dexamethasone in NS and infuse over 15-30 minutes to help minimize this side effect.

Patient Education Example: “I’m going to give you some IV Dexamethasone to help with your condition. Sometimes it can cause brief burning or discomfort in your groin, but we are giving it slowly to try and prevent that. It can still happen though, so if it does I just want you to be aware.”

Related Content:

8. Adverse Drug Reactions with Opioids

Opioids like Oxycodone or Hydrocodone are commonly given for pain and can be a great tool we can use to offer relief to our patients.

Unfortunately, opioids do have significant side effects that need to be taught to our patients.

Opioids cause respiratory depression and this is how opioid overdoses kill people.

But appropriate doses, it shouldn’t cause significant respiratory depression unless mixed with other medications or alcohol.

Opioids also cause drowsiness and even stupor, so anything that requires a high level of mental alertness needs to be avoided.

This includes driving or operating heavy machinery.

Patient Education Example: “Oxycodone helps your pain but can cause drowsiness, so you shouldn’t drive or operate any heavy machinery. It can increase your risk of falls, so be careful on the stairs. You should never take this medication with alcohol, other opiates, or benzodiazepines like Xanax or Ativan.”

Related Content: Opioid Alternative Analgesics in the ER

9. Anticoagulants and Bleeding

Anticoagulants are often necessary to prevent blood clots in those with a history of DVT, PE, or Atrial Fibrillation.

Unfortunately, they also hinder the body’s natural ability to clot when injured.

This can lead to ineffective clotting and an increased risk of bleeding. Patients on blood thinners should take extra precautions to prevent trauma like falls.

If there is a head injury, these patients should be evaluated by a medical professional, preferably within the ED where a CT scan can be obtained to rule out an intracranial bleed.

Patient Education Example: “Eliquis helps prevent blood clots, but it also increases your chance of bleeding. If you fall or sustain any injury, you should be evaluated by a doctor. If you hit your head, you should call your doctor or come to the ER.”

Every medication has adverse drug reactions, but we should be knowledgeable about these common or potentially serious reactions, and educate our patients!

Is there any other drug reaction that you are sure to educate your patients about? Let us know in the comments!

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