Nitro with a right sided MI

[ccmedoc]

I asked him about getting an EJ on a patient that was awake as the protocols say this "shouldn't" be done.

I don't understand this comment or any reason for it. We do E.J. cannulation quite a bit on conscious individuals. If you need an IV, it is a sure bet in most cases..not too traumatic in my experience.

As for nitro in inferior/right sided MI, An IV is a must for all the reasons previously mentioned. Not the best drug for the situation for sure. PCI is the intervention that is needed in this case.

[Mateo_1387]

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

Dwayne, just me thinking out loud here too.....

I would imagine that this patient is having a RCA occlusion. If he is having a massive Right sided MI I would just guess it would be his RCA with posterior involvement. But I guess we will not know unless emtgirl84 post the 12 leads that she has. The fluids provided for this MI is the keep the patient perfusing the brain. Ultimately, he needs PCI. We give the Nitro so that it reduces workload of the heart, and give the fluids to keep the patient perfusing. As far as his blockage it will most likely be due to "junk" building up on the walls of his coronaries.

From everything I have read and learned in school nitroglycerin has minimal effects on coronary dilation. Its main effect is on peripheral veins thus reducing preload and afterload. I have also been taught in school that the nitroglycerin increases collateral blood flow thus helping with the ischemia. As far as giving nitro without an IV, I have seen and heard different things. I have had a medic while at clinical go ahead and give the nitro to a patient with an inferior MI without an IV. I asked later why she did this and she told me that the drug was very beneficial and that there was no reason to prolong giving it since his blood pressure was good. It made sense to me. The patient did become hypotensive, if I remember correctly in the high 80's low 90's but we later established the IV, but most importantly took him to get his PCI. Then on the other side I know medics that would withold nitro until an IV is established. I guess this will be a call on experience. How comfortable someone feels giving the med based on what they have seen and experienced.

[ccmedoc]

you'd have to be very comfortable with the patient's stability..I've seen pressures go from 110s over 60s to 70 over 40, in seconds..not great for the patient.

In the field this makes for a VERY bad presentation to the ED.... :wink:..IV or not.

[DwayneEMTP]

I don't understand this comment or any reason for it. We do E.J. cannulation quite a bit on conscious individuals. If you need an IV, it is a sure bet in most cases..not too traumatic in my experience.

Hmmm. I'll have to check the protocols. Maybe I stepped on my weenie here. We were taught that the risk of serious infection is greater with an EJ, maybe I confused what the protocols say with something I've heard...I'll check it. Thanks for the response.

Dwayne

[ccmedoc]

A lot of places used to allow IJ cannulation as well as subclavian..maybe this is what you were thinking of, Just a thought??

[Just Plain Ruff]

I had a critical 6 year old that was suffering from anaphylaxis, unable to get an iv to save her life. gave her all the goodies, epi and the like and she coded anyway. We couldn't get the iv even after the epi so I looked at her neck and hey there you are. stuck an 18 ga. in that baby. Nurses freaked, doctor didn't like it but we got the IV. We were able to bring her around.

Had we not have had the ej no telling how long it would have been before she bought the farm.

The girl is now 11 years old and is on her soccer team, star player I might add.

You get the iv where you can.

[DwayneEMTP]

Thanks Mateo_1387,

Well hell. Now I'm going to have to rethink the whole dang issue.

What got me thinking along these lines is my first preceptorship.

She asked for the EKG finding for IWMI, which I knew, but not the treatment. So I guessed, Vitals, ASA, IV, Nitro(if vitals to support it)...etc. To which she said, "Great, you just killed you patient!"

She ranted about the preload/afterload (She always ranted...I'm pretty sure she didn't possess a conversational tone of voice)

Anyway, I said, "But if we establish two large bore IVs and sit on the bags we should be able to support the pressure while improving perfusion, right?"

To which she said, for the hundreth time, "You wouldn't even make a decent basic, you have no business dealing in theoretical medicine!!!" At which point I dragged her by the hair out into traffic and danced around gleefully while she was turned into a puddle. (OK, I didn't really do that. but I did learn not to aske these kinds of questions as her grasp of A&P was too weak to be able to participate in any intelligent conversation)

Anyway. That's why this question intrigues me. I hate the "You did X and now s/he's dead!" Speaking of my past preceptor, not anyone here.

It seems to me that everything in medicine is give and take. Nothing is free. And on the flip side I don't see many "instant death" choices that aren't obvious.

Sorry, I notice I'm wandering. I just wanted to make it clear that I'm not arguing my point of view (As should be ovious from the bonehead mistakes from my previous couple of posts), only that I like the question, and appreciate the feedback.

Dwayne

[Mateo_1387]

Thanks Mateo_1387,

Well hell. Now I'm going to have to rethink the whole dang issue.

What got me thinking along these lines is my first preceptorship.

She asked for the EKG finding for IWMI, which I knew, but not the treatment. So I guessed, Vitals, ASA, IV, Nitro(if vitals to support it)...etc. To which she said, "Great, you just killed you patient!"

She ranted about the preload/afterload (She always ranted...I'm pretty sure she didn't possess a conversational tone of voice)

Anyway, I said, "But if we establish two large bore IVs and sit on the bags we should be able to support the pressure while improving perfusion, right?"

To which she said, for the hundreth time, "You wouldn't even make a decent basic, you have no business dealing in theoretical medicine!!!" At which point I dragged her by the hair out into traffic and danced around gleefully while she was turned into a puddle. (OK, I didn't really do that. but I did learn not to aske these kinds of questions as her grasp of A&P was too weak to be able to participate in any intelligent conversation)

Anyway. That's why this question intrigues me. I hate the "You did X and now s/he's dead!" Speaking of my past preceptor, not anyone here.

It seems to me that everything in medicine is give and take. Nothing is free. And on the flip side I don't see many "instant death" choices that aren't obvious.

Sorry, I notice I'm wandering. I just wanted to make it clear that I'm not arguing my point of view (As should be ovious from the bonehead mistakes from my previous couple of posts), only that I like the question, and appreciate the feedback.

Dwayne

I am all about knowing as much as you can, it definantly makes a medic more confident in his treatment.

So do you get the same preceptor for a set amount of time?

I know a lot of times in class our patients "die" when we do improper treatments, but I can't image that it happens every single time in the real world. I don't think it helps things, but it doesn't always "kill" them. Of course in class our scenarios are a lot of times based on the patient being on the verge of dying anyways

I can't really see much in ems that is x leads to y leads to z, and so on and so forth, all I see is a bunch of grey area.

[DwayneEMTP]

Mateo, I'd love a thread dedicated to this, but have no idea what the subject would be.

I'm going to move our conversation to PM, I'd like to hear more of your thoughts!

My apologies for hijacking the thread.

Dwayne

[MSDeltaFlt]

I am an EMT and I have a partner that does a lot of questionable things. I just wanted to ask for some advice and input. We get called to a patient having chest pressure. We get on scene, pt. is ambulatory. Pt. walks to the cot and we load pt. up and start treatment on scene. Pt. was shoveling the driveway when the pressure starts. Pt. describes it as being in the middle of the chest and a little bit of back pain and it is more of a pressure type feeling than pain. Pts. medical history is high cholesterol and a smoker. Pt. is in late 50's and does have a family history of MI. Pt. is also vomiting. My partner can't hit an IV after 3 attempts. I set up the 12-lead and what I see is not "normal" to me. I am just getting ready to start a medic class so I haven't learned how to read a 12-lead yet, but when I printed off the strip it say acute mi at the top. We are 45 minutes out from the nearest hospital and we do have access to a chopper 1 mile down the road. Pts. vitals are 98/P pulse is running 50-55, O2 sat is 94, pt. has some shortness of breath, as well as vomiting, color looks like crap...grayish, and pt. is clammy. My partner gives her a spray of nitro with no IV line established and then we take off. We go non-emergent. We had sent the EKG to the hospital en route....next thing I know, dispatch is telling me to tell my partner to contact the hospital immediately. The hospital precedes to explain to my partner that this pt. is critical, having a right side MI and needs to go straight to the cath lab. It's almost like my partner didn't even know what was going on or how to read the strip. I then get upgraded to emergent. We get to the hospital and the doctor's are pissed! Pt. goes staright to the cath lab and my partner gets to have a little talk with the supervisor. My partner says that he is "sick" and that is part of the reason he made poor decisions. What are your thoughts?

EMTgirl, you had a middle-aged man with new onset midsternal pressure and back pain, borderline BP, and bradycardia. Regardless of what the 12 Lead said, I wouldn't give NTG without a line. If I couldn't get a line in the arm, I'd go EJ. I'd go EJ in a heartbeat regardless of what the protocols said. I do this because my med controls know me and trust me, and they expect me to do what the pt needs. I'm just that aggressive.

Regardless of the situation, a middle aged man is not supposed to have a HR that damn low and having pressure in his chest. That is just not supposed to happen. So I would get aggressive on that alone; even more aggressive with what I believe your 12 Lead said to boot.

Some may agree. Some may not agree. Those are just my thoughts.

With respect.