Home is where the heart is redux

[Mogollon]

Good deal, I find many people want to run for the atropine or an antiarrhythmic. When people have conduction disturbances and arrhythmias, we need to always consider an electrolyte abnormality. In this case, the patient had a very low potassium.

Is there another electrolyte abnormality we need to consider?

[Medic_QT]

NaHCo3 too low, since the K+ is so high? The only other one I'd think of is Ca+..

[Mogollon]

Potassium is low in this case, but you are correct, because hyperkalemia can be the result of acidosis. You also want to consider the magnesium. Magnesium alterations can also be pro- arrhythmic.

[GaHazMedic]

and getting rid of our GTN drips and bringing in nitro paste.

That's a step back. There's a reason we moved from NTG paste to drips in the first place. if the pt starts to crash, it is extremely difficult to stop the action of the paste, the absorption of the paste is a guess at best making it hard to get an accurate dosing. These are just a few of the reasons drips are better than paste.

[Medic_QT]

Potassium is low in this case, but you are correct, because hyperkalemia can be the result of acidosis. You also want to consider the magnesium. Magnesium alterations can also be pro- arrhythmic.

Durr. That makes sense.. Mag sulfate for torsades. I'm not completely blonde I swear.


That's a step back. There's a reason we moved from NTG paste to drips in the first place. if the pt starts to crash, it is extremely difficult to stop the action of the paste, the absorption of the paste is a guess at best making it hard to get an accurate dosing. These are just a few of the reasons drips are better than paste.

I just sit on the committee, and I had to fight to get there even. Very few medics who work here have critical care experience, and those who do, can't fight the MD powers that be. Lots of people here think nitro paste will be easier, which it is, but "one inch" shouldn't be a dosage. You can squeeze the tube at like 5 different thicknesses. I don't mind having the nitro drip. There's a reason we used them in STEMI's at the ER, and rarely used nitro paste. I learned the hard way that nitro paste sucks, and you can't get it off. A nurse thought it'd be funny to wipe it on my arm one night. I tried washing it off, started flushing, and I ended up trendelenburg in the nurses station, because I usually only run 100/50-110/60 to begin with. The only thing I can say, is that I think people on my department will be more apt to use nitro paste, vs the drip, even though we have an EMP pump, preset, ready to go, SOLELY FOR NITRO. I would say more, but I may blow a vessel or two getting fired up...

[Mogollon]

Durr. That makes sense.. Mag sulfate for torsades. I'm not completely blonde I swear.



I just sit on the committee, and I had to fight to get there even. Very few medics who work here have critical care experience, and those who do, can't fight the MD powers that be. Lots of people here think nitro paste will be easier, which it is, but "one inch" shouldn't be a dosage. You can squeeze the tube at like 5 different thicknesses. I don't mind having the nitro drip. There's a reason we used them in STEMI's at the ER, and rarely used nitro paste. I learned the hard way that nitro paste sucks, and you can't get it off. A nurse thought it'd be funny to wipe it on my arm one night. I tried washing it off, started flushing, and I ended up trendelenburg in the nurses station, because I usually only run 100/50-110/60 to begin with. The only thing I can say, is that I think people on my department will be more apt to use nitro paste, vs the drip, even though we have an EMP pump, preset, ready to go, SOLELY FOR NITRO. I would say more, but I may blow a vessel or two getting fired up...

No problem. Tosades aside, simply having low magnesium levels in the absence of any other problems can be pro-arrhythmic.

Regarding the GTN: There are actually people looking into the infusion versus paste. One of the Ph.D. qualified clinical educators for my employer has been gathering data with some interesting results. (Nothing definitive at this point) It seems in the rural setting, patients are experiencing significant delays in door (or point of access in our case) to intervention times related to crews mixing infusions, calculating doses, and fighting with the IV pumps. In fact, providers working under GTN paste protocols seem to package faster and patients arrive at definitive care faster. Does this change M&M, I am not sure at this point. Additionally, medication errors appear to be a concern as well. People have to mix the meds and calculate doses. The chance of error is always higher in these situations. Hence the reason JCAHO made the big push against nurses mixing medications like potassium.

In conclusion, the change to GTN paste may seem counter intuitive; however, potential benefits exist for such a modality. Therefore, I am not going to write it off until we have some definitive results.