treatment for the brady MI

[zzyzx]

Do you guys think the bradycardia is due to the heart decompensating? Or is it a protective response to the MI? Or is it due to the ischemia knocking out the SA node (hence the junctional rhythm)? I don't know the answer to this, but I'd like to hear other opinions. I think the answer would greatly effect one's treatment of the patient.

[AZCEP]

It will actually be a bit of all three.

The heart rate is slowing down because of the inability to perfuse itself, and damage to the SA node is a good possibility. The bradycardia can also be induced by a vagal response to the areas that are being damaged.

The treatments that have been mentioned will help some with all three as well. Oxygen/ASA/NTG, maybe/Dopamine, possibly/Rapid transport to PCI or fibrinolytics. If the rate stays where it is great, if if slows further big problems. If it speeds up too much, the MI gets bigger. This is the best example of balancing good and bad responses in prehospital care.

Our goal needs to be to balance the rate increase with the perfusion of the myocardium. Tricky at best. :wink:

[Thunderchild145]

Our protocols here say dopamine is contraindicated with AMI, So I would try atropine, 0.5mg every 3-5 up to a max dose of 3, try to get up her heart rate and improve BP. I would try to not give too much though cause I would not want to increase the myocardial damage.

[Ridryder 911]

Our protocols here say dopamine is contraindicated with AMI, So I would try atropine, 0.5mg every 3-5 up to a max dose of 3, try to get up her heart rate and improve BP. I would try to not give too much though cause I would not want to increase the myocardial damage.

That's interesting, when is your indication to use Dopamine, if it is not cardiogenic shock? As well, Atropine is great, unless they have a block of second degree or higher.. then, you can stand back and watch the infarct size increase. If it is not reflex bradycardia, I much rather pace..

R/r 911

[Thunderchild145]

Eh. I was wrong. It's not actually contraindicated but because it tends to increase myocardial oxygen demand it is not recommended in the protocols. (Class IIb) After rereading it it doesnt say "contraindicated". Just says "with caution"

[Ridryder 911]

True it does, but there is nothing else prehospital personal can do.. like paddling up stream with the use of one hand. Most of these patients require balloon pump therapy.. and that has not been approved in EMS (U.S.) Few of us oldies might remember that in Ireland (I believe) they were using a similar counterpulsation device connecting to the descending/femoral artery in the field, about 20 years ago or s.... appeared to be successful, but have not seen any more literature on it though.

R/r 911

[poc]

Atropine only has an effect on the part of the heart innervated by the vagus nerve. This stops at the AV junction. You will probably not get much of an effect with the Atropine. Pacing would be more helpful ( if you can get capture). According to most patients (strictly speaking of my own experience) pacing is not so much "painful" as it is "uncomfortable". I understand that we want to decrease their discomfort; hopefully the pacing will increase perfusion enough to give some nice sedation and pain meds. I also agree with a judicious fluid bolus. Dopamine will possibly by helpful but you may not get the desired effect, even at high doses, if this pt has a hx of CHF or has been in cardiogenic shock long enough to deplete her norepi stores. Also, at this patients age, thrombolytics become a little risky.