Question

A 42- year old male patient has been admitted to the unit with a diagnosis of coronary artery disease with a 75% blockage on one side. He is scheduled for angioplasty today. He has a history of depression and alcoholism but states he has not had a drink for 1 year. The heart monitor indicates increased premature ventricular contractions (PVC’s). The nurse notes a 30 second run of ventricular tachycardia and will initiate standing orders for a lidocaine infusion. Standing orders read: “For episodes of ventricular tachycardia, give a loading dose of 50 mg of lidocaine IV push, repeat this dose in 5 minutes, and then begin a continuous infusion of 1 mg/min IV, do not exceed 200-300 mg over 1 hour.”

What factors will the nurse consider before beginning the lidocaine infusion and why?

What will the nurse monitor while the patient is receiving the lidocaine infusion and why?

4 days later your patient is ready for discharge. The angioplasty was successful and the patient has not had any complications. The patient will be discharged on Quinidine 400 mg every 12 hours. 2 months later, he calls the clinic and states that he is hearing “ringing in his ears” all the time.

Is the ringing sound the patient claims to hear a significant issue?   Why?

This is reported to the physician and the medication is changed from Quinidine to Procainamide. The patient questions the nurse about the medication and its side effects.

According to the Vaughan Williams Classification table, what functional class does Procainamide belong to? What action does it have?

How will the nurse answer the patient’s question about Procainamide?

Answer 1

Ventricular Tachycardia: A heart attack involving a heightened heart rate in a ventricle of the heart.

Lidocaine( 2 diethylamino N acetamide) : is a local anaesthetic drug also used as antiarrhythmic drug

1. Nursing consideration prior to Lidocaine infusion :

* Monitor vitalsigns ( temperature, pulse, respiration and Blood pressure) and pain score, if the pain is present, . This provides the base line data.

* Check whether the patient is allergic to Lidocaine. Some are sensitive to Lidocaine. Lidocaine infusion may lead to serious hypersensitivity reactions in sensitive people.

* The clinical area should be equipped with Cardiac monitor, pulse oximetry and resuccitative equipments etc. Lidocaine infusion may affect cardiac function and can lead to cardiac abnormalities.

* Check the weight of the patient . Lidocaine treatment may lead to weight gain in some patient

* Kidney function test and liver function test should be checked. Liver and kidney abnormalities are the contraindications for lidocaine infusion.

During lidocaine infusion :

* Continuous monitoring of patient to detect any early signs or symptoms of toxicity such as headache, tremors, Hypertension, twitching etc.

* In case of any signs or symptoms like visual hallucination, hypotension, confusion , seizures or agitation, report to physician immediately and stop the infusion otherwise these toxicity symptoms may lead to complications.

3. Quinidine

An isomer of Quinine that is used as an antiarrhythmic agent.

' Ringing in ears ' or tinnitus, that occur as a side effect of Quinine. Tinnitus is the perception of noise such as ringing or beating sound, which has no external source. It is a significant issue as it may be a symptom of ototoxicity of Quinine medication, if left untreated it may lead to hearing loss.( also cause anxiety, insomnia, depression etc.)

4. Procainamide

It is an antiarrhythmic drug, used in the treatment of Cardiac arrhythmias.  

According to Vaughan Williams Classification, Procainamide belongs to the Class la.

Action: Procainamide is a Sodium Channel blocker of cardiomyocytes ( cardiac muscle cells). It also act by inhibiting potassium current , as a result of these action , it slows the conduction velocity of heart. Thus act as an antiarrhythmic drug. ( arrhythmia is an irregular heartbeat).

4. Nurse's response to patient

Procainamide is a medication for cardiac dysarrythmias. It will not cause any tinnitus or ' Ringing in ears' . The side effects are rare.

It may  cause nausea and vomiting some times.

Report to physician:

any sign or symptoms of Allergy such as itching, hives, wheezing, tightness of chest etc.

severe diarrhoea

signs of lupus such as joint pain or rashes