What would you do...

[tcripp]

I enjoyed to discussion on the last one I posted...I thought I'd have a "part deux". Okay...here's another "what would you do".

You are called for a 45yom, possible cardiac event. Arrive on scene to find classic AMI signs and symptoms in your assessment and you find an "in your face" STEMI in leads II, III and aVF. You call it right sided and begin your treatment accordingly...O2, ASA and IV and withhold NTG/Morphine because that's what you have been taught.

Lung sounds are clear/equal/bilateral; skin color is "gray"; cap refill > 2 sec; diaphoretic; no pedal swelling; no JVD. (Let me know if you need more detail...)

You now find yourself on a long haul (1.25 hour transport) because there is no air transport available. You have a STEMI protocol at your disposal (plavix, heparin and lopressor) in addition to standard chest pain meds and your narcs include fentanyl, morphine, valium and versed. Your patient's vital signs are more than stable, not what you'd expect for right sided; BP stays at 150/100 and HR stays at 70.

What is your treatment plan for that long ride?

[Flasurfbum]

Does the pt still have pain?

[Bieber]

Is this an inferior wall MI or just right sided? What does V4R say? Anyway, assuming I have at my discretion and authority to treat with those medications as I wish, this is my treatment:

*Nitro x3 or until systolic <100 (actually, I think wants it gets in the 110-120's I might go ahead and reassess from there) or pain 0 with a fluid bolus running concurrently and another on hand for severe hypotension, with fentanyl substituting that if no relief after x3 nitro and holding both if the patient's pressures start going down. Basically, if I can keep my preload good and still dilate those coronary arteries, that's my goal.

*Gonna hold on the Lopressor. Yeah, it's not a bradycardic right sided AMI, but the rate's about where I want it to be anyway (and maybe it'll come down with some pain relief, too) and I don't want to stunt the SA node any more if it's part of the infarcted tissue.

*Heparin 60 U/kg up to 4,000 units bolus then 12 U/kg/hr up to 1,000 units per hour.

*Plavix 300 mg PO.

[tcripp]

Does the pt still have pain?

Yes. 8/10.

Is this an inferior wall MI or just right sided? What does V4R say? Anyway, assuming I have at my discretion and authority to treat with those medications as I wish, this is my treatment:

ST Elevation in V4, V5 and V6.

[Paramagic]

My question is why you have called it right sided? You don't have V4R to confirm it, and haven't mentioned the degree of elevation in II as compared to III. Further, if the patient has elevation in V4, V5, V6 and II, III and aVF this would suggest a left dominant circulation with a reasonably proximal LCX occlusion, which would make right sided involvement highly unlikely.

I'll leave the discussion of giving with one hand and taking away with the other by giving fluid and nitrates for another time; at this stage treat as per your ACS protocol, this is an inferolateral infarct.

[Chief1C]

What would you do

Call 9-1-1

[fiznat]

Call on-line medical control and discuss this case with the receiving doc.

[tcripp]

My question is why you have called it right sided? You don't have V4R to confirm it, and haven't mentioned the degree of elevation in II as compared to III. Further, if the patient has elevation in V4, V5, V6 and II, III and aVF this would suggest a left dominant circulation with a reasonably proximal LCX occlusion, which would make right sided involvement highly unlikely.

I'll leave the discussion of giving with one hand and taking away with the other by giving fluid and nitrates for another time; at this stage treat as per your ACS protocol, this is an inferolateral infarct.

Sorry - I must not have been very clear. The RV4 (or V4R) read additional elevation in V4 - 6.

Also, the point of this exercise is to get a feeling of what various ACS protocols are...in compared to mine.

Call 9-1-1

Cute. I assume you mean, ALS backup?

[Paramagic]

Sorry - I must not have been very clear. The RV4 (or V4R) read additional elevation in V4 - 6.

Also, the point of this exercise is to get a feeling of what various ACS protocols are...in compared to mine.

Sorry, I misundertood. So V4R, V5R and V6R are all elevated. Obviously that changes the game somewhat, now that we have a proximal RCA occlusion.

Aspirin and plavix PO. No O2 unless he becomes hypoxic or starts to really look awful. IV access x 2, large bore with crytalloids hanging on both TKVO at this stage, ready to start squeezing. No LMWH for me unfortunately. Fentanyl for pain relief, as much is necessary. I'd have my atropine drawn up, along with my inotropes/pressors.

Now, what I would not do is give nitrates. We are all aware that this patient is, or will become, very much preload dependant to maintain his cardiac output. I very much disagree with the idea of trying desparately to maintain preload with fluids, only to take it away with nitrates. The primary reason we give nitrates is to reduce preload and thus myocardial workload. They have a variable effect on coronary vasculature and this is also impeded by the fact that we are dealing with sclerosed and occluded vessels. There is also no compelling evidence that nitrates reduce mortality in ACS. So the risk is I obliterate his blood pressure compared to the benefit of.... nothing. Not a very good Risk/Benefit comparison there.

I'm not an advocate of helicopters whizzing around all over the show, but with that kind of transport time and an evolving infarct this patient would benefit greatly from primary PCI in as short a time frame as possible, so that would be my first choice. I do not carry thrombolytics, but I have several 24/7 cath labs available within a 30 minute or so transport. This patient could feasibly benefit from thrombolysis if it is available.

[Chief1C]

Cute. I assume you mean, ALS backup?

The title was Right Side MI, What would you do... Well, if it's me, I'd call 9-1-1. However, out here in the sticks. I'd likely fly them to a hospital that could treat them, rather than have them wait it out at the nearest band-aid ER so they can be transferred later on.