Nitro with a right sided MI

[brock8024]

Why did you not give oral glucose. I mean you can rub a little around on gums and under tongue. that a very vascular place. SO you did do two ekg's right to check for right sided mi

[EMTgirl84]

Oral glucose was given by my partner. 2+ EKG's were done....I had my husband look at them for his opinion (he is a medic) and he said that he could see the patient going from bad to worse.

[spenac]

Why did you not give oral glucose. I mean you can rub a little around on gums and under tongue. that a very vascular place. SO you did do two ekg's right to check for right sided mi

Go rectal with oral glucose. Less chance of aspiration.

[vs-eh?]

Even without any cardiac monitoring at all and simply by going with your history as stated and vital signs, an inferior MI +/- RVI is reasonable.

Add to that the fact you have a 12 lead (that showed acute inferior MI) and did V4R (with ST elevation), diagnosis becomes significantly more solid.

There is this new fangled (yes I said fangled) drug called ASA. Funny enough it is actually the BEST medication that most can give prehospital for these kinds of patients. ASA actually reduces mortality, nitro (regardless of patient) and analgesics do not.

Can't get an IV? Meh, I would be quite cautious anyway with SL dosing or morphine/fentanyl. Fluids would probably be equal if not more of a concern.

ASA and oxygen with a proper history and monitoring are fine.

[Ridryder 911]

Although V[sub:f9c43a1790]4[/sub:f9c43a1790]R is great, one can detect a ride side without such. Even basic XII lead interpretation along with other clinical indicators (borderline BP, Bradycardia) should be noted as red flags indicating right side, possible inferior wall involvement. Even without a XII lead, moderate blood pressure and bradycardia should have been a tale tale sign.

With other indicators, it appears this medic may have good intentions, but that itself is not enough. It appears this medic needs to be reconditioned and possibly evaluated. Maybe some refresher over AMI, etc. then if not better, fired. Sorry, give a chance then not better time to move on.

Hopefully, these physicians will make contact appropriate persons before this medic causes more harm than good.

R/r 911

[ptemt]

Her original post says that the partner gave the pt a spray of nitro and off they went, with no IV access established.

I wouldn't give nitro with a BP that low and a patient looking utterly like crap... perhaps I need some more education as to nitro use however.

Would you give nitro in an unstable MI with a systolic BP above 100 for pain relief? Or would you give something else, like morphine? Why?

Wendy

CO EMT-B

With right ventricle MI, giving nitro could be detrimental due to the vasoldilation reducing preload and making the heart more ischemic. Better have an IV first and be ready to challenge with volume.

I trust a member of the COE will slap me straight.

[DwayneEMTP]

Yeah, with a 45 minute transport it's hard to imagine not getting a line of this guy. Every indicator says Inferior/right sided MI. Borderline BP, a little brady, pale, sweaty, nausea, vomiting. The medic should have been thinking Inferior/right sided MI before the monitor was ever placed.

This patient needs treatment. For the treatment he needs a line. EJ if nothing else. Push the fluids to build the pressure you need to medicate is what I'm thinking. We need to dilate the coronary arteries, this is most likely going to be accomplished with nitrates. Push the fluids until you get your pressure, deliver the nitro, and monitor your pressure.

It seems to me, and I could be wrong, that the "Tons of fluid and no nitrates/vasodilators" rule for inferiorwall MI with right sided involvement is great in a perfect world, or for a snappy anti-intuitive response to someone new to cardiology, but I can't really make the physiology line up in my head as a hard and fast rule. In the real world this guy needs coronary perfusion. We can fudge the pressure with saline, but there's not really any pretending the hearts being perfused if it's not...right?

If time is muscle, something needs to be done to feed the pump long before the 45 minute drive to the hospital is complete...

Once again I probably should have researched this instead of pulling it out of my rear, and made some attempt to appear as at least slightly less dorkish...Yeah, well. That's never been my strong suit.

Dwayne

[CBEMT]

People seem to be dealing very gently with this situation.

To me, he sounds like a trainwreck of a medic.

[Ridryder 911]

Dwayne, I believe you are making it too hard. Think on the line of preload and after load effect. )Starling Law effect) Actually NTG is not really contraindicated but not suggested, especially when you have a presentation of such.

I agree if possible a line should have been attempted, in which I believe the poster described. I know many services have policies on how many and as well, many do not allow EJ's on conscious patients.

The difficulty of establishing a line is not really surprisingly though, bradycardia and low blood pressure ( brady producing low B/P or low ejection fraction r/t AMI). Then especially, after NTG is administered.

Something I am sure that the medic learned off, and hopefully will never do that it again.

R/r 911

[DwayneEMTP]

Dwayne, I believe you are making it too hard. (I'm probably looking for zebras...)Think on the line of preload and after load effect. )Starling Law effect) Actually NTG is not really contraindicated but not suggested, especially when you have a presentation of such.

Rid, I'm certainly not arguing with you, but would like to run my logic by you for your thoughts.

I understand that we need to manage preload/afterload, as Starling's law is much more important now than it is normally. But if the LAD is blocked, and if there is significant right sided involvement we know it must be blocked pretty high, wouldn't the heart benefit from the arterial dilation that "might" (I have no idea if this is logical or not) at least move the block lower in the artery so as to effect smaller protions of the myocardium?

Just thinking out loud...

Also, on the EJ. The medic I ride with put an EJ in a gunshot victim that was bleeding badly from the right bicept. Fire had attempted 4-5 IVs in one arm, we were attempting to get one in the leg...all of them blew out almost immediately! 8-9 attempts, all unsuccessful. (In the trauma bay they also made, I think, 6-7 attempts before getting a 20g started. I never heard the theories on what was going on with this guy's vascular system.) So the AMR medic got an EJ. After, I asked him about getting an EJ on a patient that was awake as the protocols say this "shouldn't" be done. He told me, "He needed an IV, not an excuse. You DO NOT want to go to our medical director and explain to him that you couldn't practice medicine because "the protocols said so", not if you want to continue to practice under his license." I love this system...

My opologies for the distraction in the thread, but I've found that many people have many different ideas on this, so perhaps it isn't a terrible sin...

Dwayne