Interesting AMI call w/NTG debate

[treaux]

So I'll give a quick recap of the funny parts of this call first, without trying to be too hard. So I respond from about 15 minutes away to a call for a 50y/o male patient with "Chest Pain." Upon arrival at the scene, there are already two Sheriff's Deputies there, I hear angry voices upon walking in and the first thing the fire captain says to me upon walking in is "Just hang back, it looks like this is going to be an AMA." So I peak in to see a very agitated man sitting on his bed with his shirt off reluctantly letting fire do a 12 lead on him and constantly trying to get up and saying "I'm fine, I'm fine, leave me alone." He also vehemently denied any CP or SOB, though he admitted to some "tingling" in his left shoulder and arm. I can see from across the room what looks like pretty significant lead II ST elevation and I asked the captain if the pt had any cardiac hx. Captain says he has nothing except for emphysema, some alcoholism and ITP (a blood thinning disorder that reduces platelets). So sure enough the 12-lead comes back showing significant elevation in II, III and aVF as well as some slight depression in the anterior leads. This is when I step in and tell the patient that he needs to go to the hospital and that he is having a very serious cardiac event. I try to explain to him that he is having a heart attack and he simply says "I'm not having a heart attack." He continues to argue (in addition, a bit of ETOH on board as well) with me and adamantly refuse to even let us get a fresh blood pressure. He proceeds to rip off the leads and starts storming around his house. He ends up going into the other room and lighting up a cigarette and when we try to approach him he just storms past us. I get a physician on the line on speakerphone who repeats to the patient that he is having a heart attack and will likely die if he doesn't go into the hospital.

Long story short, I eventually convince him to get on our gurney (this is after 20 minutes on scene already!) after talking him out of having his wife drive him (she was crying anyways and begging him to go with us). We have about a 30 minute transport even code 3 due to our location so after getting him in the ambulance we take off right away. I redo the 12-lead on my monitor and transmit it to our STEMI center and I put the tourniquet on to start a line (I prefer to have a good line before administering NTG to an inferior MI). Within 2 minutes of us going in route and as the patient was mid-sentence telling me how much alcohol he had that day, his eyes roll back in his head and down he goes. Pulseless, apneic and in v-fib on the monitor. I have my partner pull over and notify the engine that we need a rider. As my partner hops in the back to grab a BVM I get the pads on the patient and deliver one defib at 200J. Before my partner can pull the BVM out of the bag the pt lifts his head up and asks "What happened?" I told him what had just happened and he says "well I still feel fine." By this time the rider has hopped in and we start rolling again. We get a couple of IVs established and I gave some lidocaine for the post v-fib status (yes, we still use that here). Pt's BP drops a little, but still in the 160/80 range and he has literally zero ectopy and a perfect sinus rhythm all the way into the hospital. He STILL denies any CP even after the defib (ETOH likely a culprit here) and we get him in and up to the cath lab right away.

So after this fairly intense call I do my usual self review.

First thing off the bat was that I wish I had taken a rider in the first place. I've run in tons of MIs without one and it's gone fine, but hindsight is 20/20. I've also had a septic patient who were extremely stable code on me in the back of the rig with no fair warning and no rider as well during a code 2 transport. Am I going to take a rider on every septic patient from a con home? No, but I'll likely be bringing one with me on every STEMI transport that's more than a few minutes away from the hospital.

Second off was debating giving NTG post v-fib conversion, especially in an Inferior MI (where a good percentage of them have a right sided MI aspect and NTG could possibly bottom out their pre-load and cause more problems). Granted this patients BP was pretty high, but I have had other patients with right sided MIs drop 40-60 points systolic after a single NTG administration. I also read an interesting JEMS article regarding the possibility of NTG even CAUSING v-fib (http://www.jems.com/...nt-goes-prehosp).

Lastly, I didn't know too much about ITP before this call, but after a little reading it makes this an interesting case study as AMIs are unlikely with people who have ITP. My patients unhealthy lifestyle (2 packs a day and heavy ETOH) may have been prolonged even by his condition basically keeping his blood thin all the time. Another interesting article I found on STEMIs for pt's with ITP: http://cardiologyres...ewArticle/11/25

Anyways, I welcome discussion on the topic. Would you or would you not give nitro post conversion? They were in no rush to do so at the hospital and preferred instead to get him straight up to the cath lab.

I have copies of his ECG and the v-fib conversion and will try to get them scanned shortly.

[BushyFromOz]

Sorry man, im not sure what your asking. If its about GTN my answer is no. The pt is denying "chest pain" pr se (even with the shoulder tingling) but the inferior on an already unstable patient even with a B/P of 160 would be a no go zone to me... and thats a pretty big statesment as going by the book (our book) he is indicated for it, so i'd withold and keep frank-starling happy. Also, at 50 y/o i dont think he is likely to have well devloped significant collateral circulation, so there is a chance the GTN will have minimal effect with a whole lot of risk attached.

Treating with aspirin and diesel is more than appropriate, he either gets drano from the local hospital or a chopper ride to a PCI lab.

[Paramagic]

On iPhone so please excuse typos. I'm with bushy. This patient presumably has an occlusive event occurring, and I would have no expectation of nitrates doing anything beneficial. Nitrates have not demonstrated any benefit in AMI, and the risks of giving them far outweighs the non-existent benefit. I have never seen any compelling reason to give them to patients who are, or are potentially, preload dependent. I'm always perplexed by the idea of giving fluids to increase preload, in order to give nitrates to decrease preload. Strange and frightening...

The other thing (and I'm sure you'll be doing this anyway in the future) is that all my STEMI patients get defib pads applied, as it is very reasonable to expect arrythmia and/or arrest, especially in those early hours of the infarct.

[treaux]

I agree with your statement Bushy, hence why I did not administer any NTG on this call. Just curious as our protocol as would dictate to give it, and it's our discretion to not administer as appropriate. As Paramagic said as well, the risks outweighed the benefit in this case. However, I did read a while back about some testing done that came to a conclusion that administering NTG increased the v-fib threshold, which is why I have posed the question.

I haven't put defib pads on every STEMI patient in the past and I'd say I transport around 30-40 a year. This is the first STEMI patient I've had that has gone into v-fib. I'm not sure if it will change my practice as it only takes seconds to put the defib pads on someone. It certainly wasn't a hindrance on this call.

[systemet]

A few quick points as I have to rush:

* Sounds like your patient R on T'd, and went into VF. This is fairly common in STEMIs. I once had back to back calls when this happened. One patient was an right/inf/post MI that a rehab hospital had given 3xNTG to, and presented to me w/ 68/30 as an initial BP before coding within minutes. Another was an inferior MI with no right changes, normotensive, who I gave a single NTG to, and watched code 5 minutes later, complete with hypoxic seizure. Post-resus 12 showed right sided changes. Possibly post-defibrillation stunning, but probably not.

* I wouldn't give NTG here, especially in the absence of CP and in the immediate post-resus period. Tread gently here. Almost all badness improves with a couple of minutes of doing nothing, including most post-resuscitation arhythmias. There's no evidence that NTG improves long term outcomes in acute MI.

* You describe inferior STE and anterior STD, this sounds suspicious for inferoposterior wall MI (?R waves in V1-V4, with significant STD). This suggests a right coronary occlusion, which suggests RVMI. Was the STE in lead III > lead II? Were you able to get right-leads? Did you have time for a post-resus 12?

* I wouldn't attribute the lack of pain post-defib to intoxication. I had (yet another) patient with a STEMI code on me, and post-resus @+5 minutes her complaint was "I feel kind of cold, what happened?"

* It sounds like a challenging call with an emotionally charged scene and an intoxicated patient. You got them to go to the hospital, and dealt with the arrest, and you learned some stuff for next time. Good job.

[craig]

Sorry man, im not sure what your asking. If its about GTN my answer is no. The pt is denying "chest pain" pr se (even with the shoulder tingling) but the inferior on an already unstable patient even with a B/P of 160 would be a no go zone to me... and thats a pretty big statesment as going by the book (our book) he is indicated for it, so i'd withold and keep frank-starling happy. Also, at 50 y/o i dont think he is likely to have well devloped significant collateral circulation, so there is a chance the GTN will have minimal effect with a whole lot of risk attached.

Treating with aspirin and diesel is more than appropriate, he either gets drano from the local hospital or a chopper ride to a PCI lab.

what about us giving the draino bushy......some of us can do that now....

I agree with your statement Bushy, hence why I did not administer any NTG on this call. Just curious as our protocol as would dictate to give it, and it's our discretion to not administer as appropriate. As Paramagic said as well, the risks outweighed the benefit in this case. However, I did read a while back about some testing done that came to a conclusion that administering NTG increased the v-fib threshold, which is why I have posed the question.

I haven't put defib pads on every STEMI patient in the past and I'd say I transport around 30-40 a year. This is the first STEMI patient I've had that has gone into v-fib. I'm not sure if it will change my practice as it only takes seconds to put the defib pads on someone. It certainly wasn't a hindrance on this call.

I am with bushy

protocol here states that the Pt must have 'chest pain'....seeing he has no chest pain he dont get it, how ever if you feel that he needed it you could attempt to steer him to telling the truth about the chest pain....'does it hurt here" when point to a spot on his chest....voila....chest pain

I might hold off a little on the metalayse if the Pt went in to a Vfib arrest..........gee the stuff just about kills em any way.........

[BushyFromOz]

what about us giving the draino bushy......some of us can do that now....

So they should, unfortunately department of health is so busy screwing things it will be a while before they can find some of that money being blown on bullshit and use it for something useful.

Of course, the city ICP's transmit their twelve lead and have a ridicuously short door to PCI time.... rural people just get screwed over that little bit more.

[ambodriver]

First off....sounds like you did a great job on this call.

Good work!!

Second, I also would not have given the NTG, I don't see the benefit in this situation.

Again, great job!

[AZCEP]

First off, nice situation to be thrown into without much help from your colleagues.

Typically, if the patient's presentation does not include significant discomfort, which this patient's doesn't sound like it did, NTG should not be considered. The ECG tells you it might be a bad idea to throw a fixed amount at them, so I think you did the right thing.

Lidocaine is still extremely useful for the AMI with ventricular ectopy. This patient made it pretty easy for you to make that decision so kudos.

[Paramagic]

Lidocaine is still extremely useful for the AMI with ventricular ectopy.

Ahhhh...... what? Useful how?