A clinical scenario for pharmacy students
Started by BenJammin
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I'm only a P1 in my first week of class, but I would guess atropine because nitroglycerin lowers blood pressure but I don't know if it does anything to heart rate. Finally, as a tech I learned that atropine is for bradycardia. That's my elementary reasoning, I'm wondering what the licensed pharmacists will say. 🙂
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Well, I could be stupid, but the patient is bradycardic (apparently not a word?), so give the atropine. Nitroglycerin doesn't treat bradycardia as far as I know.
To the poster above me, Nitroglycerin doesn't decrease heart rate, but it isn't going to help the underlining cause of the chest pain. I seem to recall you can get reflex tachycardia. Maybe not though, not 100% sure about that.
Anxiously await to learn how wrong I am. 😳
To the poster above me, Nitroglycerin doesn't decrease heart rate, but it isn't going to help the underlining cause of the chest pain. I seem to recall you can get reflex tachycardia. Maybe not though, not 100% sure about that.
Anxiously await to learn how wrong I am. 😳
Sinus bradycardia = no nitroglycerin. Atropine is given instead.
A: You wonder why the hell the attending physician at an ED doesn't know this, resign your position, and get a job elsewhere.
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I'm also glad as hell y'all aren't taking care of me.
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I'm also glad as hell y'all aren't taking care of me.
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Need more information (even in real life) before deciding on treatment
Probably getting a full set of vitals, 12-lead EKG, start 2 large bore IVs (and a rainbow panel of labs) and a stat portable CXR, while asking the nurse to apply Zoll Pads onto the patient.
So my answer would be - neither for now because I don't know what's going on (and the differential is very broad with many pitfalls) and you don't want to make a bad situation worse - "primum non nocere"
What if it's Lance Armstrong at his peak and his basal HR is like 43?
What if he is experiencing right coronary ischemia which is causing his bradycardia and you give him freaking atropine?
What if they have an allergy to atropine somehow...(lulz)?
Perhaps they take Viagra...oh nos, the death hypotension.
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True, so many unanswered questions.
I think my original answer about going to work elsewhere is the correct one.
What if he is experiencing right coronary ischemia which is causing his bradycardia and you give him freaking atropine?
What if they have an allergy to atropine somehow...(lulz)?
Perhaps they take Viagra...oh nos, the death hypotension.
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True, so many unanswered questions.
I think my original answer about going to work elsewhere is the correct one.
I have a feeling the answer the OP is looking for is going to be nitro if said poster rewrote the question to involve being in the middle of the woods with no diagnostic equipment, but nitro drips and atropine amps laying around for whatever reason...
Warfarin!!!
Acls!
ACLS Protocol
http://www.uhems.com/medcommand/protocols/2012_protocols/Chapter4ACLSPROTOCOLS.pdf
With sinus bradycardia, you do not give nitroglycerin.
http://www.uhems.com/medcommand/protocols/2012_protocols/Chapter4ACLSPROTOCOLS.pdf
With sinus bradycardia, you do not give nitroglycerin.
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Fentanyl!!
if signs and symptoms compatible with MI, don't you give MONA first to stabilize (morphine, oxygen, nitoglycerin, and aspirin). if the patient is hypotensive indicating unstable, dont you taking straight to cath lab? low HR of 39, you give atropine, what if patient has an a clot? do you want to give him an MI?
Can some body please second, or correct the above?
I like this question!!
Can some body please second, or correct the above?
I like this question!!
I'm thinking some Soma + Lortab + Xanie bars will fix this patient right up.
I think docusate IM + Au IV + EtOH rectal should do the trick...
Atropine ?? Anyway I hope the OP gives us the answer. I suck at critical care 🙁
Atropine ?? Anyway I hope the OP gives us the answer. I suck at critical care 🙁
I would want more info, at least basics such as age/gender/weight/what they were doing when pain started, to better guestimate the possiblity they are having a heart attack. Since they are apparently stable, have them chew a couple of baby aspirin while waiting for their bloodwork. Disclaimer...I never had an ER rotation or haved worked in an ER pharmacy, so I hope I don't sound too dumb. 😳
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The differentials are too broad to formulate a definite plan of action - it could be an MI, but it could be severe heart failure, sepsis +/- shock, saddle PE with severe right ventricular strain/failure, Mobitz II or Type III heart block, drug overdose, hypothermia, electrolytes abnormalities (potassium, magnesium, calcium, phos), aortic dissection, critical aortic stenosis, cardiogenic shock, etc. For all we know, it could be a COPD exacerbation in someone with sick-sinus syndrome, or a recent drowning patient (in winter time) who had chest compression done to expel water from the lungs
As to MONA, nothing wrong with giving oxygen. Even with an MI, be careful ... if the 12-lead indicate ST-elevation along the inferior leads, then you want to do a right sided EKG to make sure the right ventricle/RCA isn't involved ... otherwise giving nitro will make a bad situation worse (beta-blockers can also be bad). Also due to popularity of Viagra/Cialis/Levitra, watch out when giving nitro (as WVU so elegantly stated above)
If the bradycardia is due to a dysfunctional AV node or SA node from ischemia, I would be wary of giving atropine since you will increase tissue oxygen demand. Also low doses of atropine have been known to worsen bradycardia instead of fixing bradycardia
So it really depends on what's going on, how the patient looks, what is the patient's medical history (if available), and how stable is the patient. We don't even know if this bradycardia is sinus brady or junctional rhythm. Is the patient awake, or is the patient lethargic, or unresponsive?
*this is coming from a perspective of a CCM doc, and not necessarily an EM doc but usually the initial evaluate and stabilize workup are similar
How does knowing the heart rate (off of a pulse) tell you that it's sinus brady? As others have stated, you need to know more than "pain and bradycardia" to make any sort of a judgement on this.
To the OP, this is not a question that can be answered with the information you gave us. Please give more information so we can have a good discussion.
Also, as a followup, I pose this question: Patient presents with cough: RIPE or gefitinib?
His right coronary was ischemic which is messing with his AV node. Give him nitro and you'll slowly see his heart rate go back to normal. Give him atropine and you'll probably kill him. This came from a real life scenario too! Pretty interesting stuff. I think the point the resident was trying to make was that the chest pain is more worrisome than the bradycardia so it should take emphasis until you get a better idea of what's going on. Doing otherwise could kill someone.
Thank you!!!
Choosing only between those two options without any additional info, I'd swing RIPE as NSCLC's 5 year mortality rate really doesn't lend to a hell whole of a lot for an intervention anyhow. This reminds me I should go watch tombstone again
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I would be very hesitant to give nitro, knowing that the RCA is involved to the extent that the AV node is dysfunctional. Nitro will reduce your preload, and with a severely weaken RV, you may cause reduced pulmonary flow, reduce cardiac output, leading to cardiogenic shock. In addition, reducing vascular tone will also drop SVR (in the setting of cardiogenic shock), which can be very bad. Generally, nitroglycerin is contraindicated when there is right ventricular involvement (and generally, the RCA supplies the RV, and 20-30% of the LV, and posterior descending artery if the patient is right-side dominant). The AV node is supplied by a branch off the posterior descending artery (if right-side dominant, otherwise, it is supplied by a branch off the LCx)
In the above case, the patient/physician/pharmacist got lucky that there was no sudden (and fatal) drop in systemic pressure or vfib. I would have applied zoll pads, and if unstable, started transcutaneous pacing (or prepare for transvenous pacing) while the patient is being rushed to the cath lab.
To address Praziquantel86, the answer is neither. You first treat with azithromycin and after it fails, you switch to levaquin. After that fails, you place the patient on doripenem, tobramycin, and linezolid. After 2 weeks and no improvement, you can switch to a 15 month duration of rifampin, ethambutol, and clarithromycin. After 15 months and no improvement, you finally decide to talk to the patient, suspect allergic rhinitis, give claritin +/- nasonex, and resolve the cough. 😛
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Choosing only between those two options without any additional info, I'd swing RIPE as NSCLC's 5 year mortality rate really doesn't lend to a hell whole of a lot for an intervention anyhow. This reminds me I should go watch tombstone again
For NSCLC - depends on stage. If caught at an early stage (stage 1A or stage 1b), surgery followed by adjuvant chemo (if stage 1B) leads to decent 5-year survival (60-80%, some suggest 90% now that CTs are catching NSCLC at earlier stages). The percent of disease returning (either a new primary or relapse) is still present so close surveillance is needed following treatment.
In addition, if the NSCLC is adenocarcinoma, testing to see if the cancer has the EGFR mutation may improve outcome since EGFR+ adeno tend to respond well to gefitinib. Testing for ALK-rearrangement may also make sense since there are studies that show some improvement in survival (at 1 and 3 years) for patients who have ALK-rearrangement and receiving crizotinib.
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Neither, I'd give a beta-blocker and some epi. That should help with the chest pain
Don't be silly. You realize that the poll was 10-2 atropine, right?
So, like I said, if'n you were in the middle of the woods with a nitro drip and an atropine amp, and you got slow heart and chest pain...the answer you were looking for is nitro.
Yup, figured that's what you were trying to get at...
Oh god, don't talk about antibiotics, you'll make Z splooge his pants and write a 13 paragraph rant with the blah blah cidal blah blah static crap nobody cares about.
😍 Different strokes, different folks. I'd much rather go to a presentation about ID than a ball game any day of the week. 👍
I bet your favorite cookie is Lorna Doone.
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I really never have understood why SO MANY pharmacy students love ID. It's so boring. All it ever boils down to is see microbe, kill microbe, don't kill human. I understand there are usually complications with that an all...but that's all it really boils down to. I couldn't yawn furiously enough through that stuff.
Now metabolic ****...all the receptors and ****...that's interesting.
Lulz.
I'd give TPA - duh
That **** cures everything. It's like ED Robitussin.
