AFIB RVR on EKG: Management of Atrial Fibrillation

AFIB RVR on EKG: Management of Atrial Fibrillation

William J. Kelly, MSN, FNP-C
William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

Atrial Fibrillation (AFIB) and AFIB RVR are common conditions that you’ll see as a nurse within both inpatient and outpatient settings. These patients are often asymptomatic, but may have severe symptoms and even be unstable, especially with AFIB RVR.

Recognizing AFIB on the monitor/EKG and knowing how to treat it is important as the nurse, as you’ll be on the front line with these patients!

AFIB RVR Atrial Fibrillation Featured Image-min

What is Atrial Fibrillation (AFIB)?

Atrial Fibrillation (AF or AFIB) is an “irregularly irregular” arrhythmia that usually occurs in a structurally diseased heart.

AFIB occurs when too many atrial impulses are usually coming from the pulmonary veins, causing rapid fibrillation or “quivering” of both the left and right atria.

Remember, the heart has four chambers: left and right atria on the top and left and right ventricle on the bottom. With AFIB, the top chambers are in a constant state of fibrillation.

During a normal heartbeat, the atria first contract, pushing blood into the ventricles, and the ventricles then pump the blood to the rest of the body. In AFIB, the atria lose this “atrial kick,” leading to ineffective atrial filling and decreased cardiac output, especially at rapid rates.

Cardiac Conduction Review

It is helpful to remember how the cardiac conductions system works to understand what is going on with AFIB.

Remember, the heart has specific electrical conduction tissue, which creates and moves the electrical signal throughout the heart to produce an organized rhythm. This organization lets the heart fill and pump effectively.

Cardiac Conduction System: AFIB RVRThe heart’s pacemaker is the sinus node located in the right atrium. This region of cells creates the “normal” impulse and sends it throughout the atria and then through the AV node. This AV node normally slows the conduction to allow for ventricular filling. The PR interval on the EKG denotes this slowing of the conduction.

Once traveling through the AV node, the impulse goes through the Bundle of His. It splits down the left and right bundle branches towards each ventricle, then through the Purkinje fibers and eventually the ventricles, causing a heartbeat.

In AFIB, rapid-firing comes from the atria, usually where the pulmonary veins meet the left atria. This leads to the quivering of both atria and ineffective atrial filling and atrial kick.

While the AV node does slow down conduction, it can only do so much on its own. With such rapid firing from the atria, many of these impulses want to make it down to the ventricles and cause heartbeats.

As you can imagine, this can lead to very fast heart rates – what we call AFIB RVR or rapid ventricular response.

What is AFIB RVR?

AFIB RVR (Rapid Ventricular Response) occurs due to the frequent electrical impulses from the atria.

The AV node is only able to slow the frequent electrical impulses down so much, so many of the impulses are conducted through to the ventricles, leading to a rapid ventricular response or a fast heart rate >100bpm and often much faster.

Patients with these fast rates are often symptomatic and may become hypotensive. These patients will usually require IV medications to slow down their rate, and possibly even electrical cardioversion (more on that later!).

What causes AFIB?

AFIB usually occurs in predisposed hearts and is often set off by reversible triggers.

Chronic diseases which predispose the heart to AFIB include:

Atrial Enlargement

Anything causing atrial enlargement such as CHF, Cardiomyopathy, COPD, OSA, obesity

Valvular Heart Disease

Rheumatic Fever, aortic stenosis, valve repelacements, etc

Ischemic Heart Disease

Coronary artery disease, past or current myocardial infarctions (heart attacks!)

Usually, some reversible trigger throws the patient into AFIB. These reversible triggers include:

Surgical Procedures

CABG or heart transplants, usually within the first 2 weeks postop

Pulmonary Emblolisms

PEs can cause right atrial heart strain and Increased pulmonary vascular resistance

Alcohol

Alcoholics and binge-drinking can cause Holiday Heart syndrome, which can occur in 60% of binge drinkers

Drugs

Cocaine and amphetamines can increase sympathetic tone and leave the heart predisposed to arrhythmias such as AFIB

Hyperthyroidism

Hyperthyroidism (low TSH) can cause increased sympathetic tone and lead to arrhythmias

Hypomagnesemia

Low magnesium levels can lead to AFIB, generally levels < 1.5 (check this).

Medications

Certain medications can trigger AFIB including Theophylline and adenosine.

Caffeine

Although caffeine is often thought of as contributory to ectopy and AFIB, there is no direct evidence it does trigger AF. However, it is something to consider.

Nursing Assessment of AFIB RVR

Symptoms of AFIB

Up to 44% of patients with Afib are asymptomatic. Patients with faster rates are more likely to develop symptoms, and those with CHF are more likely to experience hemodynamic instability and severe symptoms (aka low BP and possible code situation).

Some symptoms of AFIB can include:

Fatigue

Most common complaint

Dypnea

Shortness of breath

Diaphoresis

Sweating

Dizziness

Dizziness or lightheadedness

Palpitations

Fluttering or skipping in their chest, or possibly just feeling their heart pounding

Chest Pain

Chest pressure, pain, or discomfort

Syncope

Loss of consciousness

The Physical Exam

Inspection

  • Pallor or flushed
  • Diaphoresis
    • May appear tachypneic

    Vital Signs

    • BP: May be low at fast rates and with poor cardiac output
    • Pulse/HR: Often >100 (RVR)
    • Respirations: Normal or increased
    • SPO2: Usually normal

    Auscultation

    • Lungs
      • Usually Normal
      • May have crackles if CHF
    • Heart
      • Rapid and irregular rate

    Identifying AFIB RVR on the ECG

    Atrial fibrillation (AFIB RVR)

    AFIB will NOT have visible P waves. Instead, there will be a fibrillatory baseline. There is no depolarization wave throughout the atria, but rather rapid twitching and many “small” depolarizations, firing at rates 350-600 times per minute.

    The QRS complex should be narrow unless an underlying intraventricular conduction delay is present, such as a bundle branch block.

    The T waves may be difficult to decipher between the F-wave baseline completely. T wave abnormalities are common, including T wave flattening.

    AFIB is irregularly irregular. This means that the R-R interval is continuously changing, and there is no pattern.

    AFIB can be at any rate, but faster than 100 is considered AFIB RVR. Without medications to slow it down, rates are usually between 90-170 bpm.

    AFIB: Atrial Fibrillation Notes

    Initial Nursing Interventions

    STAT EKG

    Any patient with cardiac symptoms should get an EKG.

    Patients with new AFIB should have a 12-lead EKG to confirm the diagnosis.

    If the patient is at significant fast rates, keep them hooked up to grab another one once the rate improves or the patient converts.

    Cardiac Monitoring

    Patients with any cardiac symptoms should be placed on the cardiac monitor.

    Those patients with a history of AFIB with normal rates does not necessarily need a cardiac monitor.

    Oxygen Support

    If the patient is significantly hypoxic or tachypneic, apply 2-4 L/min NC to maintain SPO2 >90%.

    IV Access

    Start two peripheral IVs at least 22g, but preferably one at least 20g. If they are in AFIB RVR, they will likely need an IV Cardizem drip and IV heparin in separate lines.

    If there is a concern for pulmonary embolism or embolic stroke, make sure to place an 18-20g in the AC.

    While drawing blood, make sure to draw a blue top as PT/INR, PTT, and a D-dimer may be ordered.

    Unstable Tachyarrhythmia

    Remember that any unstable tachyarrhythmia should follow ACLS guidelines. This means the patient may need electrically cardioverted. If they are unstable (Low BP, impending arrest), then place the defibrillation pads on the patient and hook them up to the defibrillator.

    Workup for AFIB RVR

    The workup will depend if the patient is in new-onset AF or already has chronic AF and if they are in RVR or not.

    Patients with a known history of AFIB who have controlled rates don’t need any specific testing. They are usually on chronic medications to control their heart rates and anticoagulants to prevent blood clots.

    Patients with new AFIB or AFIB RVR require more extensive testing, and the workup may depend on their symptoms.

    General workup for new AFIB includes:

    12-lead ECG

    AFIB can be diagnosed with this, as well as to look for any other abnormalities such as a STEMI

    Basic Labs

    CBC, CMP, and magnesium will often be checked

    Additional Labs

    Coag studies such as PT/INR and PTT, BNP if s/s of heart failure, digoxin level if patient is taking, and a D-dimer may be ordered as well

    CXR

    If they have any cardiac or pulmonary complaints this should be obtained

    CTA

    If there is suspicion of a PE. It May also detect atrial thrombi but is not very sensitive

    CT head

    If any altered mental status or stroke-like s/s

    Complications of AFIB

    So why do we even care about AFIB? Well, there can be disastrous consequences if we do not treat it appropriately.

    Unstable Symptoms

    Patients with AFIB have an inadequate atrial filling of blood, as well a loss of the atrial kick which pushes blood from the atria to the ventricles. This decreases cardiac output. When the ventricles have a rapid response, these insufficiencies worsen and can lead to hemodynamic compromise – hypotension, hypoxemia, and eventually cardiac arrest.

    Worsened CHF

    Patients with Left ventricular dysfunction (aka CHF with a low EF) already have a weak heart. This drop in cardiac output will be more significant, often leading to severe symptoms and an unstable patient!

    Blood Clots

    With the atria quivering – stasis of blood occurs. Remember, stasis of blood is one of the 3 factors that can lead to blood clots (Virchow’s triad). This increases the likelihood of thrombus formation.

    A thrombus in the right atria can embolize to the lungs and cause a pulmonary embolism, and a left atrial thrombus can embolize to the brain and cause an embolic stroke.

    Both of these are very serious conditions which can lead to disability and death, so prevention of this complication is important.

    Treatment of AFIB RVR

    Treatment of AFIB differs and depends on the patient’s symptoms and quality of life. This will involve at least one, but possibly all three of the following:

    • Rate control: Control the heart rate with AFIB (preventing RVR)
    • Rhythm Control: Convert and maintain the patient in a normal sinus rhythm
    • Anticoagulation: Giving blood thinners to prevent blood clot formation within the atria

    Which the Provider team and Cardiology will ultimately choose treatment options. We’ll dive a little deeper into each of these treatment options.

    Rate Control

    Rate-control is achieved via medications to slow down the ventricular response to the AFIB. Common medications include Metoprolol, Diltiazem, Digoxin, Esmolol, Amiodarone, and even magnesium sulfate.

    For AFIB RVR, we often give the following medications to control the rate:

    IV Diltiazem

    Also called Cardizem, this is more commonly given for AFIB RVR. The dose is 0.25mg/kg bolus, which is usually around 20mg. This should be pushed over 2 minutes. A repeat bolus of 0.35mg/kg can be given in 15 minutes if rate control is insufficient, and then a patient should be started on a titratable Cardizem drip.

    IV Metoprolol

    Also called Lopressor, this is especially helpful if the patient is on a Beta-blocker at home and maybe has missed some doses. The dose is 2.5-5mg IV q5m x 3. Administer the IV push over 2 minutes, and monitor rhythm and blood pressure closely. Use with caution with asthma/COPD exacerbations.

    Low BP & RVR

    One thing to point out is that those patients with significant left ventricular heart failure and AF RVR may paradoxically improve their blood pressure with rate control, so it still may be wise to administer a low dose of metoprolol or cardizem in these select patients if borderline hypotension is present. Always verify with the Physician/APP.

    Rhythm Control

    Rhythm-control is achieved via medications or electrical cardioversion. If the patient is unstable, they will be electrically cardioverted. Otherwise, the cardiologist may choose to start the patient on an antiarrhythmic such as amiodarone, Flecainide, multaq, etc.

    Many elderly patients who do not have significant symptoms will not undergo rhythm control. This is ultimately up to the cardiologist.

    Chemical Cardioversion

    IV amiodarone can be used, or the cardiologist may choose to start an oral antiarrhythmic such as Amiodarone, Sotalol, Dofetilide, etc

    Electrical Cardioversion

    Unstable patients should undergo synchronized cardioversion with the defibrillator

    Radiofrequency Ablation

    Patients with frequent symptoms (often younger patients) may undergo an ablation to burn off the area of the heart that is triggering AFIB

    Anticoagulation

    Anticoagulation is almost always used in patients with AFIB, unless there is acute bleeding or a significant risk of bleeding.

    Anticoagulation is used to prevent thrombus formation which can cause PEs and Strokes as explained above. Within the hospital, anticoagulation will include either:

    Heparin Drip

    The Provider will order a titratable heparin drip per facility protocol. This usually will have an initial bolus ordered as well. The patient’s PTT will occasionally be checked and the drip will be adjusted accordingly. Heparin drips offer quickly-reversible anticoagulation in case the patient starts bleeding.

    SubQ Lovenox

    SubQ lovenox at a dose of 1mg/kg BID can be given alternatively.

    Before being discharged, the patient is then transitioned onto an oral anticoagulant such as coumadin, Eliquis, Xarelto, Pradaxa, or ASA/Plavix.

    Coumadin

    Coumadin is much less commonly prescribed than it used to be because it requires frequent blood checks of INR, as well as dietary changes and medications, can significantly impact its therapeutic levels

    The CHADSVASC score is used to gauge risk for thrombus formation, which factors in age, sex, h/o CHF, HTN, Stroke/TIA/DVT/PE, Vascular disease, or Diabetes. If the patient does not have a high risk of bleeding such as intracranial bleeding, GIB, or frequent falls, then they are usually started on an anticoagulant.

    Clinical Pearls

    Patient Specific

    The workup and treatment will depend on the patient’s symptoms and overall clinical picture. With AFIB, there is no one-size-fits-all approach!

    AFIB RVR

    Focus on rate control and anticoagulation! Become familiar with IV Cardizem and titrating a Cardizem drip, as well as IV Lopressor!

    Unstable = Shock

    Patients who are unstable should be electrically cardioverted with a synchronized shock. Remember to press SYNC, and the dose is 50-100J. These patients will require sedation and pain control (i.e. IV fentanyl).

    Want to learn more?

    If you want to learn more about cardiac arrhythmias, 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)

    Check out more about the course here!

    REFERENCES

    Burns, E. (2021). Atrial Fibrillation. In ECG Library. Retrieved from https://litfl.com/atrial-fibrillation-ecg-library/

    Kumar, K. (2022). Overview of atrial fibrillation. In T. W. Post (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-atrial-fibrillation

    Olshansky, B. (2022). The electrocardiogram in atrial fibrillation. In T. W. Post (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/the-electrocardiogram-inatrial-fibrillation

    Phang, R., Prutkin, J. M., Ganz, L. I. (2022). Overview of atrial flutter. In T. W. Post (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-atrial-flutter

    Prutkins, J. M. (2022). Electrocardiographic and electrophysiologic features of atrial flutter. In T. W. Post (Ed.), UpToDate. Retrieved from https://www.uptodate.com/contents/electrocardiographic-and-electrophysiologic-features-of-atrial-flutter

    William Kelly, MSN, FNP-C

    Will is a Nurse Practitioner who is the founder and author of Health and Willness, an online educational platform to build clinical knowledge and skills of nurses and nurse practitioners!

     

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    Blood Pressure Crash Course for nurses

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    William J. Kelly, MSN, FNP-C
    William J. Kelly, MSN, FNP-C

    Author | Nurse Practitioner

    Blood pressure is one of the 5 vital signs, and it is so important to understand what normal and abnormal blood pressures are, and how we manage them (don’t get me started on the “6th” vital sign…).

    Within the hospital, vital signs are typically checked every 4 hours, and you will frequently run into both high and low blood pressures.

    Low blood pressure is often much more worrisome, and you may want to call an RRT if the BP is significantly low, especially when the patient is altered or has significant symptoms.

    High blood pressure is common, but often is not considered a big deal unless VERY high. In these cases, we want to slowly decrease the blood pressure instead of too quickly.

    What is Blood Pressure?

    As you probably know, blood pressure is not the pressure of your blood, but rather the pressure within your vascular system.

    The vascular system refers to your arteries and veins. When speaking of systemic blood pressure, we are specifically talking about the pressure in the arteries. 

    This pressure temporarily increases with each heartbeat, and decreases in-between each heartbeat. 

    The pressure in your arteries when your heart beats or contracts is called the systolic blood pressure. Systolic just means during the heartbeat. Systolic blood pressure can never be below the diastolic pressure.

    When the heart is not beating, the pressure “rests” back to its normal baseline pressure. This is called the diastolic blood pressure. The diastolic blood pressure should never be 0. 

    This pressure is measured in millimeters of mercury (mmHg).

    “Normal” Blood Pressure

    As we said above, systolic is the pressure during contraction of the heart, and diastolic is the pressure in-between beats. When looking at a blood pressure reading, there are two numbers: a numerator and a denominator. The numerator or top number is the systolic blood pressure. The denominator or the bottom number is the diastolic blood pressure.

    Normal systolic blood pressures are between 100 – 120 mmHG. Normal diastolic pressures are between 60-80 mm Hg. Traditionally 120/80 mmHg was considered the “gold standard” for blood pressure, but now its recommended to be at most 120/80 mmHg. 

    A "Good" Pressure

    A “good pressure” is relative. In the ER, a pressure below 160/90 tends to be considered pretty good and usually won’t require any medications. However, a pressure of 160/90 is considered very high if that is the normal daily blood pressure at home, and should be started on medications.

    How to Measure Blood Pressure

    We check people’s blood pressures in the hospital, in the outpatient office setting, and pretty much every area of patient care. Nowadays, we have machines that do most of it for us. But machines aren’t perfect, and its an essential nursing skill to know how to check blood pressure.

    In general, there are 3 main ways to check someone’s blood pressure:

    Manual Blood Pressure

    A manual blood pressure is checked using a sphygmomanometer and a stethoscope. The stethoscope if placed over the brachial artery, and the cuff is placed on the patient’s bicep.

    The cuff is pumped up to about 160 or 180 (in most people unless BP is very high). Slowly release the cuff pressure while you auscultate the brachial artery. 

    Systolic blood pressure is identified by the first Korotkoff clicking sound. The diastolic is noted when you can’t hear anything left.

    Palpating BP?

    You can palpate the patient’s radial artery when a machine or cuff is pumping up or down. When the radial artery disappears, this is your systolic pressure. There is no way to check diastolic with palpation

    Automated Blood Pressure

    An automated blood pressure is checked by a machine, often a portable Dinamap or a bedside monitor. These machines essentially perform a manual BP on their own.

    They have a sensor which detects tiny oscillations from your pulse. So when the pulse goes away – this is your systolic pressure. When the pulse reappears, this is your diastolic pressure.

    A-Line Blood Pressure

    Arterial lines are commonly placed in the ICU for strict BP monitoring. This is the most accurate way to check a blood pressure because it is directly measured by a sensor within the arteries, instead of indirectly like with the methods above. This gives you real-time changes in blood pressure.

    What’s the deal with the “MAP”?

    If you’ve been working for a bit, or in clinicals, you may hear about the term “MAP”. While systolic blood pressure is often considered the most important part of the blood pressure, the actual important number is the MAP. 

    The MAP stands for Mean Arterial Pressure. This is the average pressure in the arteries from one cardiac cycle (systolic + diastolic). This is measured by a calculation:

    But don’t go busting out your calculators. The bedside monitors should automatically calculate this for you, or possibly your EMR. If you need to calculate it, there are plenty of good online calculators to quickly do it. 

    MAP is a great indicator of tissue perfusion. If the MAP stays above 65 mmHg, then this should be enough pressure to provide essential tissue perfusion and prevent anoxic injury (injury from a lack of oxygen to the cells!).

    Nurses and Providers in the ICU will care much more about MAP than systolic blood pressure, especially when looking at low blood pressures.

    Hypertension

    Hypertension, also known as high blood pressure, comes in many different forms. While often thought of as “not a big deal”, it really is the silent killer, and can put a lot of strain on the heart, vasculature, and kidneys.

    Overtime, this organ damage becomes more pronounced, placing the patient at risk for heart disease, strokes, kidney failure, and more!

    Another reason why it’s termed the silent killer is because it often is asymptomatic – meaning there are no symptoms. But just because there aren’t any symptoms doesn’t mean it isn’t dangerous, especially in the long run. 

    In medicine, we use JNC8 guidelines to classify and manage hypertension. 

    Blood pressure levels include:

    Normal: < 120 / 80 mmHg
    Stage 1 HTN: 130 – 140 / 80-89 mmHg
    Stage 2 HTN: > 140 / 90 mmHg

    Normal Blood Pressure Levels

    Hypertension can be chronic or acute. Its also important to know if the patient is having any symptoms such as chest pain, SOB, headache, etc.

    3 main types of hypertension that we’ll talk about include:

    Primary Hypertension

    Primary hypertension, previously referred to as essential hypertension, is a chronic hypertension that has no clear cause, but is thought to involve genetic, dietary, and lifestyle factors. This is what most people are diagnosed with when they have high blood pressure. Risk factors include:

    • Increased age
    • Obesity
    • Family History of HTN
    • Black race
    • High sodium diet
    • Excessive ETOH
    • Sedentary lifestyle

    Hypertensive Urgency

    Hypertensive urgency is a very high blood pressure > 180/110 mmHg. While there is no evidence of organ damage (i.e. lack of symptoms or lab abnormalities), the patient is at risk for organ damage or strokes to occur.

    Hypertensive Emergency

    Hypertensive emergency is a very high blood pressure > 180/110 mmHg when there IS evidence of organ damage. The patient should have at least one of the following signs or symptoms:

    • Chest Pain or SOB
    • Pulmonary Edema
    • Severe headache, Seizures, or confusion
    • Elevated Troponin
    • Acute Kidney Injury (elevation in creatinine levels)

    Treatment of Hypertension:

    Treatment of hypertension is often not aggressive, and is often made by slow gradual changes to outpatient medication regimens.

    However, if the patient is symptomatic, blood pressure medications should be given. 

    At home blood pressures should be checked, as patients BPs are often higher in emergency and urgent care settings, and “White coat hypertension” is common. 

    Some oral medications used to lower BP include:

    • ACE Inhibitors like Lisinopril
    • ARBs like Losartan
    • Calcium channel blockers like Amlodipine
    • Beta-blockers like Labetalol
    • Diuretics like Hydrochlorothiazide
    • Alpha blockers like Clonidine

    In hypertensive urgency and when in the hospital, sometimes IV medications may be required including:

    • IV Hydralazine
    • IV Cardizem or Nicardipine
    • IV Labetalol
    • IV Lopressor (metoprolol)

    In general, blood pressure should never be lowered too fast. In severe cases, the goal should be to lower the MAP by 10-20% within the first hour, then another 5-15% over the next day. In many cases, this is less than 180/120 in the first hour, and less than 160/110 after 24 hours. 

    Lowering the blood pressure too quickly can actually cause ischemic damage in patients who have had elevated blood pressure for a long time. Basically the body becomes used to that high pressure, and while it is dangerous to have high blood pressure in general, lowering it too quickly can cause damage as well.

    BP & Symptoms

    When it comes to blood pressure (and even heart rates while we’re at it), its always important to ask the patient if they have any symptoms. Ask about any CP, SOB, dizziness, palpitations, headache, numbness/tingling/ etc.

    Hypotension

    Hypotension is when the blood pressure is too low. Low blood pressure is defined as any pressure less than 100/60 mmHg. However, this is often not considered true hypotension until below 90/50 mmHg.

    Patients who are small in stature and thin may have borderline low blood pressures at baseline.

    Trend Alert

    Worried about the patient’s BP? Trend what their BP has been this hospital visit, as well as previous hospital visits. If their BP is 92/48 but they always run around there and are asymptomatic otherwise – this is reassuring.

    Remember if the MAP is less than 65 mmHg, this places the patient at risk for tissue ischemia and organ damage. 

    Low blood pressure is often a serious sign, especially in the hospital setting. Common causes of hypotension include:

    Sepsis

    Septic shock is when there is a severe systemic response to infection. These patients will have persistent hypotension despite adequate fluid resuscitation (30ml/kg bolus). They usually require IV vasopressors, a central line, IV antibiotics, and ICU admission.

    Anaphylaxis

    Anaphylactic shock is a type of distributive shock that occurs with a severe allergy. Release of inflammatory mediators causes massive systemic vasodilation, swelling, and hypotension. This is treated with IV steroids and antihistamines, +/- epinephrine.

    Hemorrhage

    When the patient loses enough blood, they will become hypotensive. These patients need STAT blood, usually O negative blood that hasn’t been crossmatched. 

    Cardiogenic Shock

    Cardiogenic shock occurs when the heart can’t keep up with the body’s demand. This can occur in severe CHF or bradyarrhythmias.

    Drugs / Medications

    Maintenance medications given for blood pressure can cause low BP, especially if taken in wrong doses or if they become toxic. Some other medications have hypotension as a possible side effect such as amiodarone. 

    Adrenal insufficiency

    Patients with a history of adrenal insufficiency will often require stress-dosed steroids to maintain their blood pressure. 

    Severe dehydration

    Dehydration needs to be severe before the patient becomes hypotensive. This can occur in those with DKA or diabetes insipidus, or really anything that causes dehydration.

    Treatment of Hypotension:

    Treatment of hypotension will involve treating the underlying cause, but generally involves 2 steps:

    • IV Fluid boluses: to increase the volume of the blood
    • Vasopressors: To cause constriction of the blood vessels

    If fluid boluses do not improve blood pressure, or if the BP drops back again once its done, then the patient may need vasopressors in the ICU.

    Depending on the cause, the underlying cause should be addressed, including:

    • Blood for blood loss
    • Antibiotics and fluids for sepsis
    • Steroids for adrenal crisis
    • Steroids & Antihistamines for Anaphylaxis

    Wrapping Up

    You are going to run into TONS of patients who either have high blood pressure, or low blood pressure. Managing vital signs is a huge part of our jobs as nurses and doctors, and its so important to understand how to manage blood pressure!

    Remember these important concepts when it comes to blood pressure:

    Double Check the Pressure

    Double check your blood pressures. If it doesn’t seem right – check a manual BP. The provider may ask you to do this anyway.

    Always ask about Symptoms

    If your patients BP is high or low, ask them if they have any symptoms. Focus on any headache, chest pain, shortness of breath, dizziness, lightheadedness, palpitations, syncope, etc.

    Trend the Pressures

    Remember high blood pressure shouldn’t be corrected too quickly. Look at previous trends. Don’t freak out about blood pressures that are high unless the patient has symptoms. Worry more about low blood pressures!

    REFERENCES

    Basil, J., & Bloch, M. J. (2022). Overview of hypertension in adults. In T. W. Post (Ed.), Uptodate. https://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock

    Calder, S. A. (2012). Shock. In B. B. Hammond & P. G. Zimmerman (Eds.), Sheey’s manual of emergency care (7th ed., pp. 213-221). Elsevier.

    Gaieski, D. F., & Mikkelsen, M. E. (2022). Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock. In T. W. Post (Ed.), Uptodatehttps://www.uptodate.com/contents/overview-of-hypertension-in-adults

    Roe, D. M. (2015). Cardiac emergencies. In B. A. Tscheschlog & A. Jauch (Eds.), Emergency nursing made incredibly easy! (2nd ed., pp. 97-197). Lippincott Williams & Wilkins.

    William Kelly, MSN, FNP-C

    Will is a Nurse Practitioner who is the founder and author of Health and Willness, an online educational platform to build clinical knowledge and skills of nurses and nurse practitioners!

     

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    William J. Kelly, MSN, FNP-C

    Author | Nurse Practitioner

    A pulmonary embolism, frequently abbreviated as a PE, is a blood clot that lodges into the pulmonary vasculature of the lungs. Sometimes this can be asymptomatic, often there are mild-moderate symptoms, and other times patients can go into cardiac or respiratory arrest.

    No matter the symptoms, pulmonary embolisms can be deadly, and it is important for nurses to understand this disease and how to treat and monitor your patients with pulmonary embolisms.

    This article is part of a new series where we outline various medical conditions and the nursing assessment and management involved with each condition.

    What is a Pulmonary Embolism?

    A pulmonary embolism is a blood clot that lodges within the lungs. These are more commonly abbreviated to PEs. These can be very large or very small; only one, or many at the same time.

    The larger and more PEs that there are, the more dangerous this can be on the body. This can put significant strain on the heart, and can even cause cardiac arrest.

    Remember that a Thombus is one of the Hs and Ts to think about when a patient is coding!

    Pulmonary embolism‘s are highly associated with Deep Vein Thrombosis (DVT). You might hear the term VTE, which is an umbrella term for any blood clot within the body including DVTs and PEs.

    Pulmonary Embolism

    Causes of a PE

    There are many different causes that can cause a PE to develop, but it all goes back to Virchow’s Triad.

    Virchow’s Triad

    Virchow states that in order for blood clots to form within the body, there needs to be at least one of three things:

    Stasis of Blood

    Anything that causes blood to “sit still”

    Endothelial Injury

    Damage to the vascular system (arteries & veins)

    Hypercoagulable State

    Something that increases likelihood for clotting

    The more they have – the higher their risk of a blood clot from forming. However, a small percentage of patients won’t have any of these risk factors and still get a blood clot.

    Breaking down Virchow’s Triad, common risk factors for blood clot formation includes:

    Stasis of Blood

    • Immobility
    • Hospitalization
    • Varicose Veins
    • Atrial Fibrillation
    • Heart Failure
    • Elderly Age (>65)

    Endothelial Injury

    • Recent Surgery (especially orthopedic surgeries)
    • Trauma
    • Chemotherapies
    • Implanted devices
    • Central Lines
    • Inflammation
    • Sepsis

    Hypercoagulable State

    • Malignancy
    • Estrogen use (i.e. birth control)
    • Pregnancy
    • Inherited genetic predisposition (i.e. Factor V Leidin mutation)
    • Severe liver disease
    • Smoking
    • Obesity
    Pulmonary Embolism

    Nursing Assessment

    Patients with pulmonary embolisms usually present to the hospital or emergency department with shortness of breath.

    This is because an area of their lungs are not able to exchange gas normally. They are able to breathe in adequate oxygen, however they are unable to exchange that oxygen with carbon dioxide wherever the PE is, leading to a ventilation perfusion mismatch.

    Symptoms of a PE

    Common symptoms of a PE include:

    Dyspnea

    Also referred to as shortness of breath, and may be with exertion or at rest

    Chest Pain

    Usually pleuritic, aka worse with deep breaths or coughing

    Cough

    Usually not productive, but may have pinky frothy or bloody sputum

    Syncope

    Syncope with chest pain and SOB is suspicious for PE

    Signs of DVT

    • Extremity Erythema
    • Extremity Edema
    • Extremity Pain
    Many patients may be asymptomatic or have mild nonspecific symptoms as well, or they could go right into cardiac arrest, especially with very large PEs.

    Quick Note

    Hemoptysis is not nearly as common of a symptom in a PE as your nursing textbook may have led you to think!

    The Physical Exam

    Inspection

    • Respiratory Distress
      • Tachypnea
      • Increased work of breathing
      • Use of accessory muscles
    • Cough
    • Pallor
    • Diaphoresis

    Vital Signs

    • Temp: May have low grade temps
    • BP: Normal, increased, or decreased (severe)
    • Pulse/HR: Tachycardic
    • Respirations: Increased
    • SPO2: May be normal or low

    Auscultation

    • Lungs
      • Usually Normal
      • May be diminished
      • May have crackles if pulmonary infarct or acute CHF
      • Pleural friction rub
    • Heart
      • Tachycardia

    Quick Tip

    If a patient has CP/SOB and just recently had surgery or is pregnant, always think PE!

    The first thing you’ll usually notice is an increased rate of respirations, also called tachypnea. Patients with PEs are often in some visible respiratory distress.

    Patients with PEs often have pleuritic chest pain as well, so they’re unable to take full breaths without significant pain. This can increase the respiratory rate as they compensate by taking more frequent, shallow breaths.

    Patient’s pulse ox will often be normal unless there is significant respiratory distress. Patients may have a low-grade fever as well.

    Patience with PEs will often have tachycardia – which is a heart rate greater than 100 bpm.

    Blood pressure is often normal, but may be high secondary to pain. However very large PEs can put significant strain on the heart, causing significant hemodynamic compromise including hypotension and shock.

    When auscultating the lungs, a lot of times you aren’t really going to hear any specific bad breath sounds. You may hear some diminishment in the lung with the PE. Sometimes you may hear crackles and rarely wheezing.

    Nursing Interventions

    Cardiac Monitoring

    Place all patients with chest pain or SOB on a cardiac monitor to detect any arrhythmia that may occur and monitor heart rate.

    Patients with PEs will often have sinus tachycardia that does not completely improve with fluid administration.

    Patients with PEs can have all sorts of arrhythmias including:

    • Atrial fibrillation
    • bradycardia
    • RBBB
    • PVCs
    • VTACH/VFIB

    STAT EKG

    All patients presenting with chest pain and/or SOB should have an EKG obtained within 10 minutes of arrival.

    This is primarily to rule out any STEMI or ischemia. However, large PEs can cause significant righ theart strain.

    While they occur in < 10% of patients, signs of right heart strain on an EKG include:

    • Right heart strain pattern
    • S1Q3T3
    S1Q3T3 teaser

    Oxygen Support

    If the patient is significantly hypoxic or tachypneic, apply 2-4 L/min NC. If this is not enough to titrate SPO2 > 90%, apply a non-rebreather.

    In these cases, BIPAP or Intubation may be needed.

    IV Access

    Start a peripheral IV at least 18-20g in an AC line, as there is a high likelihood that these patients will be needing a CTA. These large bore IVs are needed to inject high-pressure dye.

    While drawing blood, make sure to draw a blue top as D-dimer may be ordered, as well as a PT/INR.

    Diagnosis of a PE

    To diagnose a PE, you will usually need advanced lung imaging, but lab work is part of the workup as well.

    Well's Criteria

    The Wells’ Criteria for PE is a clinical tool that is able to be used to determine the risk of a PE.

    This assigns points to each of the following:

    • Signs of DVT: 3 points
    • PE #1 likely dx: 3 points
    • HR > 100 bpm: 1.5 points
    • Immobiilization x 3 days: 1.5 points
    • Surgery within 4 weeks: 1.5 points
    • Previous PE/DVT dx: 1.5 pnts
    • Hemoptysis: 1 point
    • Malignancy w/ tx in last 6mo or palliative: 1 point

    Once you calculate their score, you can stratify their risk into one of the following:

    • Low risk: 0-1 point
    • Moderate: 2-6 points
    • High risk: >6 points

    Scores of 4 or less with a negative D-dimer can effectively rule out a PE.

    D-Dimer

    Blue Top blood work - DdimerOne way to minimize radiation is to obtain a D-Dimer in a patient with low to moderate suspicion of a PE.

    A D-dimer is a byproduct of fibrin which is increased in the blood whenever there is a blood clot.

    While this is a great test to see if there is a possibility of blood clots within the body, it is not very specific. This means that a negative D dimer (less than the threshold) is a pretty good way to tell if someone doesn’t have a blood clot. However, a positive D-dimer doesn’t necessarily mean there IS a blood clot in the body.

    Any bruise or minor injury can cause elevations in D-dimer, as well as pregnancy, heart disease, infections, and more.

    This means that if a D-dimer is above the threshold (around 230 but depends on your lab), then the Provider is pretty much forced to get a CTA to see if their truly is a PE.

    If a D-dimer is less than the threshold, then a PE can usually be ruled out. However, this is only the case is clinical suspicion is low to moderate.

    In patients who have a high liklihood of a PE, a D-dimer can miss a PE up to 15% of the time!

    Other Lab Work

    A troponin should be ordered in patients with chest pain and/or SOB. This can sometimes be mildly elevated in PEs, or significantly elevated if a PE causes a STEMI or NSTEMI.

    A BNP may be ordered if there are s/s of heart failure.

    Renal function should be checked before a CTA can be done, to make sure their kidneys can handle the dye. A GFR > 30 is usually adequate to obtain a CTA.

    Coagulation studies may be performed inpatient to see if there are any genetic mutations predisposing the patient to forming thrombi.

    ABGs

    An ABG may be obtained if the patient is in significant respiratory distress or has altered mental status.

    With a PE causing significant distress, you’ll typically see the following results on an ABG:

    • PaO2: Low (<80 mmHG)
    • PCO2: Low (<35 mmHG)
    • pH: Alkalotic (> 7.45)
    • HCO3: May be low (<22 mEq)

    CXR

    A chest x-ray (CXR) will almost always be ordered on patients who are suspected of having a PE, because these can rule out some other causes of chest pain and SOB such as a pneumothorax or pneumonia.

    However, a CXR is not going to pick up a pulmonary embolism. A CXR may show nonspecific signs including atelectasis or effusions, but often will be completely normal.

    In order to actually see the pulmonary embolism, a CT pulmonary angiography (CTPA or just CTA) is required.

    CTA

    Angiography is when a radiopaque dye is injected into the patient’s vein in order to get a good look at the patient’s vasculature during a CT scan. This can be timed to look at specific areas of the heart.

    CT Pulmonary Angiography is when this is done to look at the pulmonary arteries and veins. This means the radiologist can directly visualize pulmonary embolisms.

    If the patient’s GFR is <30, we generally avoid contrast dye. However, this may be completely facility dependent.

    If a patient cannot be given the dye (GFR < 30 or anaphylactic reaction), the alternative test is to obtain a V/Q Scan.

    Pulmonary Embolism

    V/Q Scan

    A VQ scan is a nuclear medicine test where they use radioisotopes in conjunction with X-rays to see if there are any ventilation/perfusion mismatches. Well this is not as definitive as a CTA, it does give probabilities of their being a PE, such as a “very low probability”.

    Quick Note

    The patients CXR really should be a clear study, otherwise the VQ scan will be poor quality. So if the patient has significant consolidation or pleural effusions, the VQ scan is unlikely to be very sensitive to finding a PE.

    Treatment of PE

    Treatment of a patient with a PE who is hemodynamically stable will generally consist of admission to the hospital, parenteral anticoagulation, and then transition onto an oral anticoagulant.

    Patients who have significant hemodynamic compromise may require reperfusion therapy.

    Parenteral Anticoagulation

    Treatment for pulmonary embolisms primarily involve anticoagulation.

    In the hospital setting this is usually IV unfractionated heparin. This Heparin is given as a Heparin drip, which is titratable depending on PTT levels. Each facility should have their own heparin drip protocol.

    In general, a bolus dose is given IV (can push fast), and then a slow drip is started. The PTT levels are usually checked every 6 hours but will depend on the protocol.

    SQ Lovenox is an alternative to IV heparin, and is given in a dose of 1mg/kg BID.

    But how does anticoagulants really help if the blood clot is already there? The role of the anticoagulants are to prevent further clots from forming, as well as to stabilize the clot from moving. This can be especially helpful if there is a DVT or an atrial thrombus within the heart. These can embolize and cause further PEs or even strokes.

    Quick Note

    I’ve found that usually IV heparin is ordered because this is more easily titrated and can be stopped quicker in case there is any bleeding or procedure that need done while inpatient.

    Oral Anticoagulation

    Sometimes the patient can be started directly on an oral anticoagulant and discharged home if they are otherwise stable, but this will depend on the Provider and the facility standards.

    Eliquis for PEOnce the patient is stable enough for discharge, they are started on long-term oral anticoagulation, such as Eliquis or coumadin.

    Patients with very recent surgery, hemorrhagic stroke, or active bleeding are not started on anticoagulation.

    Patients will often need to stay on the anticoagulation for at least 3 months, but sometimes longer. The blood clot should be reabsorbed by the body in about 6 weeks, but will depend on the size of the thrombus.

    Some patients will require life-time anticoagulation if they are found to have any genetic predispositions to blood clots. This is also true for patients with atrial fibrillation.

    IVC Filter

    IVC Filter for PEAn inferior vena cava filter, commonly referred to as an IVC filter, is a device that is sometimes placed to “catch” clots before they enter the right atria.

    This is usually placed in for patients who cannot be on anticoagulation, or those who have gotten repeat PEs despite anticoagulation therapy.

    They can be temporary and need removed eventually, but some that are placed are permanent.

    Thrombolytics

    In patients who are hemodynamically unstable from their PE, thrombolytic therapy can be given to dissolve the clot. This is like TPA in a stroke, but given for a PE.

    However, there are many contraindications to thrombolytic therapy, and there is a risk of bleeding.

    Procedural Removal

    An Embolectomy can be performed if needed and if the facility is capable of doing so, particularly when thrombolytic therapy is unsuccessful or cannot be used due to contraindications.

    There are additional procedures that can be done to retrieve / break up the clot including:

    • Ultrasound-assisted thrombolysis
    • Rheolytic embolectomy
    • Rotational embolectomy
    • Suction embolectomy
    • Thrombus fragmentation
    • Surgical embolectomy

    Many facilities will not have these capabilities, but most should have thrombolytics.

    Saddle PE

    A Saddle pulmonary embolus is a very large PE located at the bifurcation of the main pulmonary artery. These PEs are rare but likely to cause significant hemodynamic compromise and cardiopulmonary respiratory arrest!

    Patient monitoring

    Monitoring the patient will mainly consist of monitoring their vital signs and supporting them however you can.

    Oxygen Support

    Monitor their oxygen status by respirations and pulse oximetry. Stable patients may only need q4h vitals.

    oxygen delivery devices and flow rates - simple maskIf their oxygen is low or if there is significant respiratory distress, titrate up their oxygen levels.

    A BIPAP or Intubation may be needed in severe cases.

    Blood Pressure Support

    Monitor their blood pressure per department protocol.

    If hypertensive, treat with analgesics and antihypertensives.

    If hypotensive, treat with fluid boluses, paying careful attention to respiratory and cardiac status. 

    Vasopressors may be required in severe cases.

    Cardiac Monitoring

    These patients should have telemetry ordered. 

    Monitor their cardiac rhythm per department protocol, and notify any changes to the Provider.

    Bleeding / Falls

    These patients are usually placed on anticoagulation as above. Be sure to place the patient on fall precautions, and monitor for any bleeding.

    Titrate the heparin drip according to protocol, and a high PTT may require that you stop the heparin drip for some time.

    Clinical Deterioration

    If the patient begins to deteriorate, be sure to notify the physician or APP and/or call an RRT.

    Remember that PEs put strain on the heart, so patients can go into flash pulmonary edema. Those with pre-existing CAD may have heart attacks.

    Overall Pulmonary Embolisms are a serious medical condition that can be deadly, so it is important to know how to treat these patients at the bedside.

    Do you have any crazy PE stories? Let us know in the comments below!

    REFERENCES

    Haag, A., et al (2022). Pulmonary embolism. In R. I. Donaldson (Ed.), WikEM, The Global Emergency Medicine Wikihttps://wikem.org/wiki/Pulmonary_embolism

    Sharma, R. (2022). Pulmonary embolism | Radiology reference article. Radiopaedia.org. Retrieved February 8, 2022, from https://radiopaedia.org/articles/pulmonary-embolism

    Tapson, V. F., & Weinberg, A. S. (2022). Treatment, prognosis, and follow-up of acute pulmonary embolism in adults. In T. W. Post (Ed.), Uptodatehttps://www.uptodate.com/contents/treatment-prognosis-and-follow-up-of-acute-pulmonary-embolism-in-adults

    Thompson, B. T., Kabrhel, C., & Pena, C. (2022). Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism. In T. W. Post (Ed.), Uptodatehttps://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism

    Thompson, B. T., & Kabrhel, C. (2022). Overview of acute pulmonary embolism in adults. In T. W. Post (Ed.), Uptodatehttps://www.uptodate.com/contents/overview-of-acute-pulmonary-embolism-in-adults

    Want to learn more?

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    Pulmonary Embolism: A nurses reference Guide

    William Kelly, MSN, FNP-C

    Will is a Nurse Practitioner who is the founder and author of Health and Willness, an online educational platform to build clinical knowledge and skills of nurses and nurse practitioners!

     

    STEMI & NSTEMI: A Nurse’s Comprehensive Guide

    STEMI & NSTEMI: A Nurse’s Comprehensive Guide

    Understand the key differences in a STEMI & an NSTEMI including how to detect a STEMI on the EKG, the different kinds of STEMIs, and the acute management involved including which medications to give!

    Blood Transfusion Reactions: A Comprehensive Nursing Guide

    Blood Transfusion Reactions: A Comprehensive Nursing Guide

    William J. Kelly, MSN, FNP-C
    William J. Kelly, MSN, FNP-C

    Author | Nurse Practitioner

    Blood transfusion reactions are common within the hospital setting because so many blood products are given. Transfusing blood products that are lacking or actively being lost (i.e. GI bleed) is literally life-saving treatment.

    In this article, we will talk about the different blood products, why they are given, and then dive into each type of blood transfusion reaction, what causes them, their signs and symptoms, and how to manage them as the nurse.

    Acute Hemolytic Transfusion Reaction

    What are blood products?

    There are multiple different blood products that are transfused within the hospital, and each one can have adverse reactions called blood transfusion reactions.

    Packed Red Blood Cells (PRBCs)

    Packed Red Blood Cells or PRBCs are given to patients when their hemoglobin levels are low. This is called anemia. Some common causes of anemia that may need a transfusion include:

    • Acute and chronic blood loss (i.e. GI Bleed)
    • Untreated ongoing Anemia (Iron-deficiency anemia)
    • Destruction of blood cells
    • Decreased production of red blood cells (i.e. Chemotherapy, aplastic anemia)

    PRBCs are usually ordered when hemoglobin levels drop below 7g/dL, but it depends on the nature of the patient’s anemia as well as their medical history and their hemodynamic stability (are their vital signs normal?)

    1 to 2 units will be ordered of PRBCs depending on how low the patient’s hemoglobin level is, as well as if there is active blood loss. Each unit of PRBCs should increase the hemoglobin by about 1g/dL.

    Before blood products are given, a type and screen is done to verify the patient’s blood type and screen for any antibodies that may require special blood. The exception is if the patient has significant ongoing hemorrhage and the patient needs emergent blood. In this case, O Negative blood is given as they are the universal donor.

    Each unit of blood will take about 2 hours to transfuse, but the maximum amount of time is 4 hours when the blood will expire. In emergencies, blood can be run as fast as needed, often with pressure bags.

    Fresh Frozen Plasma (FFP)

    Fresh Frozen Plasma or just Plasma is the portion of whole blood that doesn’t include the red blood cells, which contains clotting factors.

    Some reasons FFP may be ordered for your patient include:

    • Massive blood transfusions
    • Severe liver disease or DIC
    • Coumadin with bleeding or surgery (in addition to Vitamin KL when Kcentra not available)
    • Factor deficiency with bleeding or surgery

    In massive transfusions, you replace 1 unit of FFP for every unit of PRBCs replaced (along with 1 unit of platelets).

    Platelets

    Platelets are a blood product that help the body form blood clots and prevent bleeding.

    These can often become low from various autoimmune disorders, cancers and chemotherapies, medication reactions, and liver disease.

    Platelets are replaced when platelet levels are low, termed thrombocytopenia. Platelets are usually ordered for:

    • Active bleeding with platelet count <50,000/microL
    • Thrombocytopenia in need of invasive procedure or surgery
    • To prevent spontaneous bleeding, usually when platelet levels <10,000/microL

    Most platelets that are given are obtained by “apheresis”. One apheresis unit is equal to 4-6 “pooled random donor units”. 1 unit of platelets by apheresis should increase the platelets by about 30K.

    Why are Blood products Given?

    Blood products are given whenever the blood levels are too low, or when there is acute bleeding. While this will depend on each specific patient and clinician, blood products are generally given when:

    • PRBCs are given when hemoglobin is below 7 or there is ongoing blood loss with hemodynamic compromise
    • Platelets are given when active bleeding with levels <50K, or when <10K.
    • FFP is given with massive blood transfusions, severe liver disease or DIC, or as a coumadin reversal option.

    Blood Transfusion Reactions

    As with any medication or fluid, there are possible adverse reactions that can occur and that you need to monitor for.

    Because we are infusing blood products from a donor, this adds an increased risk of adverse reactions to occur.

    Because of this, nurses must monitor their patients very closely during blood product transfusions. The nurse must stay with the patient the first 15 minutes of a blood transfusion (may change depending on specific facility protocol), and frequently check vital signs.

    There are common blood reactions, and then there are more rare and severe reactions that can occur.

    Acute Hemolytic Transfusion Reaction

    An acute hemolytic transfusion reaction is a rare life-threatening blood transfusion reaction to receiving blood, specifically PRBCs.

    This happens when incompatible blood is accidentally infused with the patient. This is why the patient’s blood type is checked in the first place so that an appropriate donor can be given.

    Compatible blood is outlined below:

    Acute Hemolytic Transfusion Reaction

    When having a true acute hemolytic reaction, the patient will quickly experience:

    • Fever and/or chills
    • Severe flank pain or back pain
    • Signs of DIC (like oozing form IV site)
    • Hypotension
    • Urine turning red or brown (hemoglobinuria)

    This is a severe reaction as the patient’s own immune system and the donor’s immune system attack each other, destroying blood products and causing damage in the process. The patient may experience hemodynamic instability including life-threatening hypotension.

    If this reaction occurs, the nurse should:

    Acute Hemolytic Reaction: Nursing Steps

    If an acute hemolytic reaction is suspected, the nurse should:

    1. Stop the blood immediately and check vitals
    2. Hang NS through a patent IV line. Pt should be ordered least 100-200ml/hr to prevent oliguria/renal failure, or boluses if hypotensive
    3. Notify the MD/APP and blood bank, or call an RRT if unstable
    4. Recheck identifying tags and numbers on blood
    5. Administer diuresis as ordered in those at risk for volume overload
    6. Additional testing may include DIC testing and additional blood compatibility and screenings.
    7. Transfer the patient if required

    The Provider should guide treatment, but these are serious reactions and would likely need monitoring in the ICU.

    Your facility should have a specific protocol in the event of significant blood transfusion reactions, which often involves re-testing the patient as well as re-testing the blood unit itself.

    Acute Hemolytic Blood Transfusion Reaction

    Anaphylactic Transfusion Reaction

    An anaphylactic transfusion reaction is a severe allergic reaction to something within the blood product. These are rare, with an estimated 1 in 20-50K transfusions.

    This reaction occurs seconds to minutes after starting the transfusion.

    The recipient is severely allergic to something within the donor blood, which they may have antibodies against, specifically those who are IgA deficient or haptoglobin deficient.

    Signs of an anaphylatic reaction include:

    • Urticaria
    • Wheezing and/or Respiratory Distress
    • Angioedema (facial swelling)
    • Hypotension with/without Shock

    Treatment involves immediately stopping the transfusion, and then treatment with standard anaphylactic medications. These medications include:

    • Solumedrol 125mg IV STAT
    • Benadryl 50mg IV STAT
    • PEPCID 20mg IV STAT
    • IV Fluids

    More significant interventions may be needed, including:

    • Epinephrine .3mg IM STAT +/- IV epinephrine drip with severe bronchospasm or airway edema
    • Vasopressors for hypotension
    • Oxygen and Intubation

    The blood cannot be restarted, and additional testing will need to be performed, and blood from another donor will have to be given.

    Anaphylactic Blood Transfusion Reaction

    Urticarial Transfusion Reaction

    An urticarial transfusion reaction is a less severe allergic reaction to a component within the blood products, but much more common, occurring in 1-3% of blood transfusions. This is an antigen-antibody interaction, usually with donor serum proteins.

    Patients with this blood transfusion reaction will develop urticaria (hives) with no other allergic signs/symptoms such as wheezing, angioedema, or hypotension.

    When an urticarial transfusion reaction occurs:

    1. Immediately stop the transfusion
    2. Check Vital signs and ask the patient for other symptoms (like trouble breathing or facial/throat swelling, dizziness, chest pain, etc)
    3. Notify the Provider
    4. Give IV antihistmine as ordered
    5. Restart blood if hives resolve and no other signs of allergic reaction develop

    When an urticarial transfusion reaction is diagnosed, stop the blood for 15-30 minutes, give IV antihistamine like Benadryl, and then restart the infusion once hives resolve but slowly and cautiously. Check your specific facility’s protocol.

    Urticarial Blood Transfusion Reaction

    Febrile Non-Hemolytic Transfusion Reaction (FNHTR)

    A febrile non-hemolytic transfusion reaction is exactly what it sounds like – the patient develops a fever after/during a transfusion, but they are not experiencing other signs of a hemolytic reaction.

    This is usually due to a systemic response to cytokines which developed during the process of storing the blood.

    These are very common, occurring in .1-1% of all transfusions.

    This fever will occur 1-6 hours after the transfusion begins.

    Signs/symptoms include:

    • Fever (38-39*+ C)
    • Chills
    • Severe Rigors
    • Mild dyspnea

    If the temperature is more than 39°C or 102.2°F, consider a hemolytic transfusion reaction.

    Whenever there is a fever present, the main thing to consider is if this could be the first sign of a more serious transfusion reaction such as a hemolytic reaction, TRALI (see below), or Sepsis.

    If there is just a fever and no other significant reaction is suspected, antipyretics should be be given, usually Acetaminophen 650-975mg PO. The transfusion can usually be continued but monitored closely.

    Future transfusions should be “leukocyte reduced”, which is a process that removes most of the white blood cells within the blood.

    Febrile Non-Hemolytic Blood Transfusion reaction

    Transfusion-Associated Acute Lung Injury (TRALI)

    Transfusion-Associated Acute Lung Injury, known as TRALI, is a rare but one of the severe blood transfusion reactions that can occur after transfusion of a blood product.

    This is when the transfused product activates the recipient’s neutrophils, causing acute lung damage.

    Patients at risk for TRALI include patients with:

    • Liver transplants
    • Chronic ETOH abuse
    • Smokers
    • Volume overload
    • Shock

    The patient will experience sudden and severe respiratory failure during or shortly after a transfusion, but up to 6 hours after the transfusion. This is often associated with:

    • Hypoxia
    • Fever
    • Hypotension
    • Cyanosis

    New bilateral infiltrates on CXR are often seen.

    TRALI: Nursing Actions

    When TRALI is suspected, the nurse should:

    1. Stop the transfusion immediately
    2. Check vitals and ask patient their symptoms
    3. Call an Rapid Response if the patient is in respiratory distress and/or hypoxic/hypotensive (or notify Provider in ED/ICU).
    4. Support oxygen status (oxygen, intubation if needed)
    5. Support blood pressure (fluid boluses, vasopressors if needed)
    6. Notify the Blood Bank
    7. Obtain a Stat portable CXR
    8. Follow any additional orders / administer any additional medications

    Sometimes steroids are given, although evidence is not great.

    These patients may need to be intubated and will likely need to be transferred to the ICU and closely monitored.

    They do not seem to be at increased risk for TRALI to occur again with a different transfusion in the future, however, donors who are implicated are banned from donating ever again.

    TRALI

    Transfusion-Associated Sepsis

    Transfusion-Associated Sepsis is a life-threatening blood transfusion reaction that can occur with the administration of contaminated blood products which are infected with bacteria.

    The patient will start developing signs or symptoms within 5 hours after the infusion, but usually around 30 minutes.

    Signs/Symptoms of transfusion-associated sepsis includes:

    • Fever >39ºC or 102.2ºF, sometimes hypothermia
    • Rigors
    • Tachycardia >120bpm or >40bpm above baseline
    • Rise or fall of systolic BP 30mmHg
    • Abdominal pain or back pain
    • Nausea and vomiting

    Remember that Transfusion-associated Sepsis, Acute Transfusion Hemolytic Reaction, and TRALI can all have similar symptoms.

    SEPSIS: Nursing Actions

    If transfusion-associated sepsis is suspected, the nurse should:

    1. Stop the transfusion immediately
    2. Check vitals and quickly assess the patient
    3. Notify the Provider (Call an RRT if patient unstable)
    4. Support oxygen and hemodynamic status with oxygen, fluids, etc
    5. Obtain blood work from opposite arm (blood cultures, Coombs test, plastma-free hgb, and repeat crossmatch
    6. Administer ordered antibiotics ASAP (Usually Vanco/Zosyn)
    7. Notify the Blood Bank
    8. Follow any additional orders / administer any additional medications
    Transfusion Associated Sepsis

    Transfusion-Associated Circulatory Overload (TACO)

    Transfusion-Associated circulatory overload, also known as TACO, is when the patient develops acute volume overload after administration of blood products.

    This blood transfusion reaction is fairly common, occurring in up to 1% or more of transfusions. This can occur up to 12 hours after the transfusion is given, and risk factors include patients with:

    • CHF
    • End-Stage Renal Failure (i.e. on dialysis)
    • Extremes of age
    • Small stature & low body weight

    The more units transfused and the quicker transfused, the higher risk of TACO (just like with IV fluids).

    Patients will develop symptoms of respiratory distress which include:

    • Dyspnea
    • Tachypnea
    • Hypoxia
    • Orthopnea

    The patient will also usually develop hypertension.

    Remember TRALI can have similar symptoms, as well as a pulmonary embolism.

    TACO: Nursing Actions

    When TACO is suspected, the nurse should:

    1. Stop the transfusion immediately
    2. Check vitals and quickly assess the patient (pay attention to respiratory status and breath sounds)
    3. Notify the Provider (Call an RRT if patient unstable)
    4. Support oxygen status with supplementary oxygen, BIPAP, or intubation if needed
    5. Make sure a STAT portable CXR is ordered/performed
    6. Administer diuretics as ordered (i.e. 40mg IV Lasix)
    7. Follow any additional orders / administer any additional medications

    In milder cases, the patient may just require diuretics and supplemental oxygen. More severe cases may require Bipap or intubation.

      CLINICAL TIP

    It is a smart idea for the Provider to order 20mg IV Lasix in-between units when multiple units of blood are ordered in someone with a history of CHF or who is very old. If it is not ordered and you feel it may benefit the patient, offer this suggestion to the Provider as it can prevent TACO from occurring.

    “Hey this is Jan calling from Med-surg, I just wanted to make sure you didn’t want any Lasix in-between blood units for Mark Smith in 147-2, as they have a history of CHF?”

    TACO blood transfusion Reaction

    Primary Hypotensive Reactions

    Primary hypotensive reactions are very rare, but occur when there is a sudden drop in systolic blood pressure >30 mmHg within minutes of starting a transfusion.

    The blood pressure normalizes once the transfusion is stopped. While rare, other severe blood transfusion reactions can also have hypotension, so the patient will need to be evaluated to rule those out as well.

    Patients who take an ACE inhibitor like lisinopril are at increased risk for this to occur.

    This is also more common with platelet administration.

    And those are the acute blood transfusion reactions that can occur when administering blood in the hospital.

    Keep in mind that there can also be transmission of infections such as HIV and hepatitis, although very rare and will not present itself during the transfusion or shortly after.

    REFERENCES

    Kleinman, S., & Kor, D. (2022). Transfusion-related acute lung injury (TRALI). In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-related-acute-lung-injury-trali

    Silvergleid, A. (2022). Approach to the patient with a suspected acute transfusion reaction. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/approach-to-the-patient-with-a-suspected-acute-transfusion-reaction

    Silvergleid, A. (2022). Immunologic transfusion reactions. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/immunologic-transfusion-reactions

    Silvergleid, A. (2022). Transfusion-associated circulatory overload (TACO). In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-associated-circulatory-overload-taco

    Spelman, D., & MacLaren,G. (2022). Transfusion-transmitted bacterial infection. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-transmitted-bacterial-infection

    STEMI & NSTEMI: A Nurse’s Comprehensive Guide

    STEMI & NSTEMI: A Nurse’s Comprehensive Guide

    William J. Kelly, MSN, FNP-C
    William J. Kelly, MSN, FNP-C

    Author | Nurse Practitioner

    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!

    How to read an EKG Rhythm Strip - FB Share

    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.

    You may also like: “Cardiac Lab Interpretation (Troponin, CK, CK-MB, and BNP)”

    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.

    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.

    STEMI medications

    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!

    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:

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    30 Inpatient Nursing Hacks for Med-Surg Nurses

    30 Inpatient Nursing Hacks for Med-Surg Nurses

    William J. Kelly, MSN, FNP-C
    William J. Kelly, MSN, FNP-C

    Author | Nurse Practitioner

    Med-Surg nurses can utilize nursing hacks to their advantage in order to save them time and make their shift more manageable!

    Nursing hacks are tips and tricks of the trade, sometimes new and sometimes old, which help “get the job done” quick and efficiently, while still maintaining quality care!

    If you’re not using these Med-Surg Nursing hacks, you are missing out!

    Med-Surg Nursing Hack fbs

    TABLE OF CONTENTS

    URINE HACKS

    Ok – Med-Surg isn’t all bodily excrement – but you will run into pee and poop this in most aspects of nursing within the hospital.

    There are so many poop and pee hacks to read through, you might need to take a bathroom break afterwards.

    1. Cough and Wink

    It is no secret that it can be difficult to insert a urinary catheter into some female patients.

    This is because there is so much variation in each patient’s anatomy, and the patient’s body habitus can make things difficult to see.

    Positioning, lighting, and assistance are all important, but sometimes it can still be difficult to hit the mark (in this case – the urethra).

    If you are in position and are having trouble finding where to go, have the patient clear their throat and cough. This should cause the urethra to “wink” at you if visible, making your target stand out.

    2. Foley²

    If you think you know where you’re going, or if you go in blind and end up in the vaginal canal – you may need to try again.

    One thing you should NEVER do is take the foley out, and then reinsert the same foley into the urethra (hello UTI!).

    Instead of taking out the first failed foley – leave the foley in place in the vaginal canal and open up a new kit, aiming above the catheter within the vaginal canal.

    This can help you hit the mark. Second times a charm – right?

    3. Beta-Block it Up

    No – I’m not talking about metoprolol.

    In a foley kit, there should be a betadine swab or stick that is used to clean the area before insertion of the catheter.

    After cleaning the area correctly, leave the betadine stick in the vaginal canal. Similar to the double foley trick, this should “block” the vaginal canal.

    If you aim above this – this could increase your chance of success! Don’t forget to remove the betadine stick when you’re done!

    4. Kerlix It

    Every patient on Med-Surg is different, and sometimes variations need to be made!

    For patients with larger vaginal canals, you could use a thicker material such as a clean roll of kerlix to essentially “block” the vaginal canal and helping you enter the urethra without much difficulty.

    5. Double Glove

    When putting on a foley, sterile technique is required to prevent infection.

    However, the cleanup once the foley is inserted can be messy, and your sterile gloves will be saturated with lubricant, betadine, and body fluid.

    To make it easy, before applying sterile gloves, put on a clean pair of gloves after washing your hands.

    Then apply sterile gloves as needed (you may need a bigger size).

    Once the foley is inserted and you are ready for cleanup, take off the soiled sterile gloves, and clean up everything else with your second set of clean gloves.

    You should be able to secure the foley with these clean gloves as well.

    6. TransPeeTation

    It’s inevitable with Med-Surg nursing that your patient will need to be transported all over the hospital for tests.

    Additionally, they will usually be encouraged to ambulate to keep up their strength and prevent blood clots.

    Transportation can be challenging with a foley and the last thing you want to do is have the foley get caught up on something and rip out, so this is where this nursing hack comes in handy!

    If your patient wants to get up and walk, tie a glove around an IV pole at a level below the bladder.

    Hook the foley onto this glove to use as a portable hook!

    7. Purewick

    Not so much a nursing hack – but more of a reminder.

    Don’t forget that foley catheters are not the only option you have, and they do come with risk as they are invasive and often can lead to infection.

    Many hospitals have Purewick catheters which hook up to suction to prevent the patient from lying in their own urine and causing skin breakdown.

    This can be a great option for elderly female patients with urinary incontinence.

    Also check out: 10 Nursing Hacks Every ER Nurse Should Know

    STOOL HACKS

    Another unfortunate aspect of Med-Surg nursing – you will have to clean patients up when they poop themselves.

    It’s honestly not a big deal, and you will quickly not even think twice about it.

    BUT – there are nursing hacks that can help you in some of these instances!

    8. Double Glove Again

    Foley’s aren’t the only instance where double gloving comes in handy!

    When cleaning up a messy poop situation, be sure to double glove or even triple glove with clean gloves!

    Your gloves will inevitably become soiled and you will then be able to remove the soiled pair and continue cleaning the patient without issues.

    Additionally – imagine if you only had one pair on and one of them ripped. Dead.

    9. Shaving Cream Cleaner

    We should be checking on our patients often and making sure they do not sit in their own pee or poop for too long.

    However, med-surg nursing is busy, and sometimes the poop becomes dried onto the patient’s skin and can be difficult to remove.

    Bust out some shaving cream which you should be able to find in the clean utility.

    Apply the shaving scream to the crusty poop on the skin, give it a few minutes, and wipe it off with soap and water or cleaning wipes.

    It should wipe off without issue!

    10. Constipation Cocktail

    The only person more concerned with a patient’s bowel movement than you is the patient themselves (better yet – their family members).

    If the patient is worried they may be constipated and are hoping to have a bowel movement, you could reach out to the physician and ask for something

    If the patient is truly uncomfortable, reaching out to the Provider is the best option.

    Another option is to get prune juice, put some butter in it, and microwave it for 20-30 seconds.

    This will melt the butter and the prune juice should be warm.

    The best part is this often works, there are no significant side effects, and you don’t need an order for it.

    Of course, if your patient is having significant abdominal discomfort or nausea/vomiting, you should be reaching out to the Provider regardless!

    11. Prolapse Relapse

    It was my first week off of orientation as a brand new nurse on a Med-Surg nursing floor, and I had a patient complain of rectal pain.

    I checked it out and WOW – that did NOT look right. What I was seeing was my first-ever rectal prolapse.

    This specific patient had a history of this from happening, and you can reduce the prolapse as a nurse.

    This can be done by applying some lubricant and applying firm pressure toward the patient’s rectum.

    However, sometimes large prolapses can be difficult to reduce.

    For this nursing hack, sprinkle some sugar on the prolapsed rectum and allow to sit for 15 minutes.

    This dehydrates the prolapse, causing it to shrink and making reduction easier.

    GASTRIC TUBE HACKS

    Nasogastric (NG) tubes are a nursing procedure that is unpleasant but often necessary. This is usually ordered for small bowel obstructions (SBO).

    Sticking a tube into the patient’s stomach from their nose allows suction to decompress the stomach, alleviating symptoms such as nausea, vomiting, and bloating.

    It also decreases intrathoracic pressure and improves the venous return to the heart when the patient is ventilated, as well as reduces the risk of aspiration.

    While NG tubes can really help your patient, unfortunately, the insertion procedure can be somewhat difficult. There are some nursing hacks that you can use on your med-surg nursing floor when an NG tube is ordered!

    12. NG Twisted Ice’d Tube

    During insertion of an NG tube, sometimes the tube has a tendency to curl in the oropharynx and not enter the esophagus as intended.

    In order to help this, curl the distal portion around your finger, and freeze it in ice water for 10-15 seconds. This will help it keep its curled shape.

    Insert the NG tube (with lube of course) with the curl in the direction of the pharynx (downward).

    Right before the oropharynx, twist the tube 180 degrees. This ensures now that the “hook” is facing posteriorly, and shouldn’t curl out the mouth.

    13. Numbogastric Tube

    NG tube insertions are uncomfortable for the patient, but once it is in they should get some relief.

    In order to make an NG tube insertion more tolerable, you can numb up the area first, and there are a few ways to do this.

    You can get a Urojet with 2% viscous lidocaine and squirt it up the patient’s nare in which you intend to insert the NG tube.

    Do this 5 minutes beforehand (you will need an order). While this is proven to decrease pain, it can increase the difficulty of the insertion (sticky!). See here for the full technique!

    Additionally, 3-4mL of lidocaine (2-10%) can be placed in a nebulizer and given to the patient until gone. Then immediately insert the NG.

    While this does reduce pain during insertion, it can increase the risk of epistaxis.

    14. The Medication Pulverizer

    This one is interesting, but it can make crushing meds for a PEG tube easy!

    Open an empty 10mL syringe. Take out the plunger completely, and place the pills inside.

    Re-insert the plunger up to the pills, and then aspirate 3-5mL or so of tap water.

    Next, plug up the end with a clean gloved finger, and pull back the plunger, creating a vacuum. This should crush the pills inside!

    You can then squirt this into a larger volume before administration into the Peg tube.

    If you need help visualizing this, check out this quick video!

    PICC HACKS

    PICC lines are central lines placed peripherally in the hospital setting. These are often placed on patients with very difficult access or those who will require long-term therapy such as antibiotics.

    With med-surg nursing, you will have to become comfortable dealing with PICCs: administering medications through them, as well as drawing blood.

    Unfortunately, PICC lines can get clogged up which can make either task difficult.

    But fear not – there are some nursing hacks that can help!

    15. Switching the Positions for You

    Whenever you are having a difficult time flushing or aspirating blood from a PICC line, there are some maneuvers that the patient can do which may be able to help.

    A central line occlusion can be mechanical (think kinks!), Postural (based on positioning), from medication precipitates, or from small blood clots (a thrombus).

    Often, this is positional and simple maneuvers can help with flushing or blood aspiration. Moving the arm position (raising it above their head) sometimes can help.

    You can also have the patient turn their head in the opposite direction, take a deep breath, and cough. This can increase pressure and change the positioning of the catheter and lead to successful flushing or aspiration.

    16. CathFlo Bro

    Sometimes there is a partial or complete occlusion of the central line by a thrombus. You will notice significant resistance when flushing or aspirating (or complete resistance).

    In this instance – Alteplase can be used. This is the same medication as TPA given for strokes, but at a much lower dose and intended to remain within the central line.

    When there is a partial occlusion, alteplase (also known as Cathflo in this instance) can be instilled into the PICC (2mg in 2mL). Allow to dwell for 30-120 minutes, however long it takes to successfully resolve the blockage.

    If there is a complete occlusion (aka you can’t flush it at all), you can use a three-way stopcock, create negative pressure with an empty syringe, and then slowly flush the alteplase through. This can take some time, and make sure you follow your facility’s policies and procedures.

    When you have given it 30-120 minutes, aspirate 4-5mL of blood and waste, then flush through with sterile saline.

    This can be repeated twice in a row if not successful the first time.

    Also check out: 20 Tips for New Nurses In the Hospital

    BLOODY HACKS

    Blood is something that all nurses will have to deal with in some capacity – especially nurses within the hospital.

    Whether our patients are bleeding, we are drawing their blood, or a procedure causes bleeding – it will inevitably get all over.

    Of course, nurses should be using universal precautions and hopefully, the bleeding is controlled. However, sometimes it can get messy and be difficult to clean up.

    Dried blood can be very difficult to clean, and there are a few nursing hacks that can help!

    17. Alcohol Swab

    A well-prepared nurse always has alcohol swabs in their pocket.

    If you have trouble getting a small amount of dried blood off of a patient’s skin, bust out the swab and start scrubbing.

    This is somewhat effective, although soap and water or cleaning wipes will likely do just as well. So this is especially useful for small amounts of blood.

    18. Hydrogen peroxide

    Hydrogen peroxide can be used to get dried blood out of clothing and off of skin.

    When hydrogen peroxide meets your blood, oxygen is created and bubbling/foaming is seen. This breaks down the blood and allows for it to get out of your clothing and off of dry skin.

    Following up with soap and water or cleaning wipes is beneficial.

    19. KY Lubricant

    Lube is useful for so many activities (both in and out of the hospital), but did you know it can also help with blood?

    Specifically, it helps get rid of dried blood on the patient’s skin.

    Leave the lube in place for a few minutes and then come back and wipe it up. This will usually make the removal of the blood a piece of cake. Ultrasound Gel works too!

    ArtiFACTS of Life

    Many patients on a Med-Surg nursing floor will have telemetry / cardiac monitoring ordered. This is a great tool we can use to monitor a patient’s heart rate and rhythm, but sometimes there can be difficulties obtaining a good tracing.

    Poor tracing of a cardiac rhythm is termed “artifact” and there are many different potential causes.

    Artifact can be from excessive patient movement, tremors, or shaking; but it can also be from improper application of the electrodes.

    If your patient’s monitor has excessive artifact despite not moving or shaking, try these ECG nursing hacks:

    20. Replace the Electrodes

    The electrodes could be old and dry, decreasing the conduction and quality of the ECG tracing.

    Electrodes should typically be replaced every day.

    21. Clean the Skin

    Dead skin cells, dirt, and grime can all interfere with the conduction of the ECG.

    Before applying the electrodes, try washing the patient’s chest with soap and water or a cleaning wipe.

    In a pinch, using an alcohol wipe over the areas in which you are placing the electrodes can help exfoliate the skin.

    Allow to dry before applying the new electrodes.

    22. Shave it Off

    Hair can be a big interference when conducting cardiac activity.

    If the patient is excessively hairy in the areas where you need to place the electrodes, you may need to shave them to get good conduction.

    23. Change the Equipment

    Sometimes the wires or equipment is the problem. Switch out the equipment or wires and see if you get a better result.

    24. Remove interference

    Electrical signals from other equipment can interfere with the telemetry monitor and cause artifact.

    Make sure the wires and telemetry box are not in close contact with any other equipment such as an IV pump.

    Make sure the patient’s electrodes are not overtop of a pacemaker or ICD!

    25. Make Due

    Sometimes no matter what you try, there still may be some artifact. Try adjusting the amplitude and changing the lead view to obtain the best view with the least amount of artifact.

    I also have a video course all about how to read ECG rhythm strips, which you should check out if you’re interested!

    IV HACKS

    Now this is a section that deserves it’s own post, and lucky for you I have one here!

    On a Med-Surg nursing unit, you won’t have to put in IVs as much as the ER, but it is still a skill that you will have to use and improve on. Patient’s IVs go bad all the time and they may need replacement.

    I will outline some basic hacks here, but be sure to read the full article as well if this interests you!

    26. Try Defying Gravity

    Use gravity to your advantage! Hang the extremity below the level of the heart (off the bed).

    This will cause vasodilation of the veins and increase your target vein! This will make it easier to see, feel, and cannulate!

    27. Heat it Up

    If Gravity isn’t enough, you can try a nice warm compress or hot pack! This will also cause vasodilation and increase your chance of success

    28. Nitroglycerin

    You can obtain an order for a small amount of 2% Nitroglycerin ointment to be applied to the area in which you plan to cannulate. This will also cause vasodilation.

    29. Blood Pressure Cuff

    Using a bedside blood pressure cuff can help you from blowing a vein. Pump the pressure cuff just above the patient’s systolic pressure.

    This will prevent excess pressure from the tourniquet, but still enough to engorge the veins.

    30. Start Digging

    If you don’t see a flash of blood on your first advancement, don’t give up just yet.

    Pull the needle and catheter back, re-palpate the vein, and attempt to insert in the direction of the vein again. If the patient can tolerate this, it will prevent extra pokes.

    Also check out:

    Want to Learn More?

    If you want to learn more about how to read an ECG and 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!

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