Nursing care of patient with penetrating left chest pain

Revathi^1, Ruth Saranya²

¹Emergency Ward Nursing Incharge, Kauvery Heartcity, Trichy, Tamil Nadu

²Emergency Ward Staff Nurse, Kauvery Heartcity, Trichy, Tamil Nadu

Abstract

Refractory Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF) are life -threatening cardiac arrhythmias that often lead to cardiac arrest and sudden death, especially when they are resistant to treatment. They don’t respond to standard treatments and are associated with poor outcomes, requiring advanced interventions like Extracorporeal Membrane Oxygenation (ECMO) or double sequence defibrillation. A study was conducted in Kauvery Heartcity.

Introduction

Refractory Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF) are life -threatening cardiac arrhythmia that are a major cause of sudden cardiac death, with an estimation of 3,00,000 deaths per year in the US. The incidence of refractory VF is estimated to be between 0.5 and 0.6 per 1,00,000 persons.

Background

A 51 years’ male, known case of hypertensive was brought to the casualty with complaints of chest pain on and off for 2 days. On receiving in Casualty, ECG revealed anterior wall myocardial infarction and ECHO revealed severe LV dysfunction. While receiving patient was conscious and oriented. Patient suddenly developed Ventricular Tachycardia followed by Ventricular Fibrillation followed by cardiac arrest. CPR was initiated and multiple cardioversions given with Inj.Lignocaine and Inj.Magnesium. Despite medical management, patient developed recurrent cardiac arrest and recurrent Ventricular Fibrillation, hence he was intubated and connected to ventilator in PRPC mode. Then patient was shifted to Emergency cathlab, angiogram was done through the right femoral artery, which revealed single vessel disease. Successful PTCA with stenting to LAD was done with TIMI 3 flow. Post procedure, patient blood pressure improved and patient shifted to CCU. In CCU patient developed hypotension for which IABP was inserted and his BP gradually improved. Next day patient was extubated and IABP was weaned off. His blood investigation revealed elevated total counts and hypokalemia, suspecting aspiration pneumonia for which empirical antibiotics were given. On third day, patient developed altered sensorium. Neurological opinion was obtained and suspected to have metabolic encephalopathy or hypoxic encephalopathy for which patient was treated conservatively. Patient was stabilized and shifted to ward. Patient was observed in the ward and became stable at the time of discharge.

ECG Report

ECHO Report

CAG Report

Brain CT scan Report

PTCA Report

Immediate Care

On admission ECG taken and diagnosed with acute AWMI
As preventives loading dose was given
Vital signs assessed and found painscore:4/10, BP:140/80mm Hg, HR:82/min, SpO2:96% IN RA
Both brachial IV line inserted
Duty doctor did initial assessment and explained high risk, poor prognosis and primary PCI after discussion with primary consultant
Duty doctor explained the condition to the attenders. Patient suddenly had VT followed VF, shock delivered and initiated CPR.
Patient intubated after anesthetic consult
Xylocard and Magnesium 2 gm given along with Inj.Noradrenaline for support
Cathlab intimation was done
Patient shifted to cathlab for PCI and PCI to LAD done.

Nursing Management

Patient shifted to cathlab with duty doctor while continuing CPR.
Nurses monitored vital signs and continued CPR during procedure, after stenting, patient arrhythmia
Nurses skilled in IV infusion (Inj.Tiro, Inj.Noradrenaline, Inj.Dytor) and blood sampling techniques obtained the samples for blood investigations like CBC, ESR, sodium, potassium, RFT, blood grouping, Chest X-RAY, LFT and typing serology with a sterile technique to prevent thrombophlebitis. Doctors explained the patient condition to the attenders. Nurses obtained consent for the clinical procedures after proper counselling.
In CCU patient developed hypotension for which IABP was inserted and his BP gradually improved. Next day patient was extubated and IABP was weaned off. Patient successfully extubated and weaning done. SpO2 97% in room air was maintained.
Nurses used AIDET technique (Acknowledge, Introduce, Duration, Explanation and Thank you) while communicating with patient and attenders to gain their confidence and improve satisfaction level.

Diagnosis

Coronary Artery Disease, Acute Coronary Syndrome, Acute Anterior wall Myocardial Infraction, severe LV dysfunction, Refractory Ventricular Tachycardia /Ventricular Fibrillation, recurrent Cardiac arrest-resuscitated, Cardiogenic Shock – IABP was inserted and weaned off, CAG-(16/03/2025) single vessel disease, primary PTCA with stenting to Ostio proximal lad (16/03/2025), Hypoxic Ischemic Encephalopathy (recovered), hypokalemia (corrected)

Recommendation & plan: Don’t skip medicine and review after one week
Patient stabilized and shifted to ward on 20.03.2025 & drug orders followed as per doctor’s advised
Patient discharged on 21.03.2025.

Discharged advised

Diet advice
Medication advice
Daily activity advice
Review after one week

Outcome

On discharge patient was hemodynamically stable

Discussion

After explaining poor prognosis as DIL 99% and LIVE IN 1%, patient outlived with medical miracle, and unexpecting patient recovered successfully. This patient is one of 1,00,000.

Reference

LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am. 1989 Feb. 69 (1):15-9.
Davis JS, Satahoo SS, Butler FK, Dermer H, Naranjo D, Julien K, et al. An analysis of prehospital deaths: Who can we save?. J Trauma Acute Care Surg. 2014 Aug. 77 (2):213-8.
Demetriades D, Kimbrell B, Salim A, Velmahos G, Rhee P, Preston C, et al. Trauma deaths in a mature urban trauma system: is “trimodal” distribution a valid concept? J Am Coll Surg. 2005 Sep. 201 (3):343-8.
Knuth TE, Wilson A, Oswald SG. Military training at civilian trauma centers: the first years’ experience with the Regional Trauma Network. Mil Med. 1998 Sep. 163 (9):608-14.
Schreiber MA, Holcomb JB, Conaway CW, Campbell KD, Wall M, Mattox KL. Military trauma training performed in a civilian trauma center. J Surg Res. 2002 May 1. 104 (1):8-14.
Propper BW, Gifford SM, Calhoon JH, McNeil JD. Wartime thoracic injury: perspectives in modern warfare. Ann Thorac Surg. 2010 Apr. 89 (4):1032-5; discussion 1035-6.
Inci I, Ozçelik C, Taçyildiz I, Nizam O, Eren N, Ozgen G. Penetrating chest injuries: unusually high incidence of high-velocity gunshot wounds in civilian practice. World J Surg. 1998 May. 22 (5):438-42.
[Guideline] American College of Surgeons Committee on Trauma, American College of Emergency Physicians Pediatric Emergency Medicine Committee, National Association of EMS Physicians, American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Ann Emerg Med. 2014 Apr. 63 (4):504-15.
[Guideline] Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jul. 79 (1):159-73.
Onat S, Ulku R, Avci A, Ates G, Ozcelik C. Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center. Injury. 2011 Sep. 42 (9):900-4.

Nursing care of patient with penetrating left chest pain

Nursing care of patient with penetrating left chest pain

Nightingale Journals