Nitro in Right Sided Cardiac Compromise?

[Ridryder 911]

If I'm thinking that the pt is AMI, they're getting:

O2/Vital signs

324 ASA PO

Monitor/IV access

NTG after IV access with bp checks q 3 minutes

12 lead EKG

A total of three NTG (including home NTG) and then 4mg Morphine via IV. Morphine is repeated 1mg q 5 minutes.

We transmit our 12 lead, notify the ER of a stat cath, and get them to the ER ASAP. We strive for 2 dual lumens or a total of 4 IV sites...cath lab loves us:-) 911 to open time is usually less than the 90 minute door to open time, except for long distance transports...gotta love rural EMS.

Time is muscle, no need for a 12 lead before ASA and NTG if your pt is presenting with cardiac symptoms. I run as a single paramedic provider on a squad and I can get the entire list of things done in less than 10 minutes. Then we twiddle our thumbs and wait for the ambulance! Long story short. Never withhold NTG if you think your pt is AMI. If you're thinking right sided AMI, call command after you obtain your 12 lead, hang saline, and get orders for NTG. Don't fluid overload them though...that just makes their heart work harder thus increasing ischemia and infarct.

Obviously, you have never seen many right sided AMI's! So you much rather compromise or potentialy increase the AMI size in lieu of waiting thirty seconds obtaining a XII lead prior to NTG? As an educated Paramedic, one should be able to determine if right side involvement, and then the decision to withold or administer NTG is indicated. Why chance increasing the AMI size, workload for the additional thirty seconds to make such interpertation.

R/r 911

[AZCEP]

If I'm thinking that the pt is AMI, they're getting:

O2/Vital signs

324 ASA PO

Monitor/IV access

NTG after IV access with bp checks q 3 minutes

12 lead EKG

It would be nice if you included some differential thought process in this. A good many things can make you think ACS that do not respond favorably to your protocol

A total of three NTG (including home NTG) and then 4mg Morphine via IV. Morphine is repeated 1mg q 5 minutes.

We transmit our 12 lead, notify the ER of a stat cath, and get them to the ER ASAP. We strive for 2 dual lumens or a total of 4 IV sites...cath lab loves us:-) 911 to open time is usually less than the 90 minute door to open time, except for long distance transports...gotta love rural EMS.

Why do you stop with three NTG? Perhaps more importantly why do you include the patient's own in your count? If their medication does not give the desired effect, what use is it? Your maximum amount of morphine is 4 mg? How do you justify not using more than this? Manage their pain and blood pressure, not some archaic limitation that has been placed on you by a protocol that can't possibly fit the situation.

Dual lumen IV's are a good consideration, but why two of them? The cath lab does not need this many sites for IV medications placed. If they do they will place a triple lumen central line. The dual lumens were intended for patients receiving fibrinolytics, not PCI. I can almost guarantee you that the cath lab does not "love" you, or anything about EMS. Your braggadocio of being "911 to open time" means nothing in the overall scheme of things. You need to have the patient revascularized in less time from the onset of symptoms, not from the time they call 9-1-1.

Time is muscle, no need for a 12 lead before ASA and NTG if your pt is presenting with cardiac symptoms. I run as a single paramedic provider on a squad and I can get the entire list of things done in less than 10 minutes. Then we twiddle our thumbs and wait for the ambulance! Long story short. Never withold NTG if you think your pt is AMI. If you're thinking right sided AMI, call command after you obtain your 12 lead, hang saline, and get orders for NTG. Dont fluid overload them though...that just makes their heart work harder thus increasing ischemia and infarct.

A twelve lead is a good idea as an initial assessment for the cardiac presentation. The ASA can wait a full twenty-four hours and still be effective. The NTG needs to wait until you have gathered the information that it will be safe and effective. Too many situations can be made worse that don't need to. If you can get the entire list done that quickly then you are missing some steps, or taking some unnecessary shortcuts.

Why do you need to call anyone to give NTG to an MI? You have already stated that you can give it without your 12 lead being done. Following the steps you've mentioned you give the NTG, watch the blood pressure plummet, then not refill the tank with fluid, then call for approval of a medication? Giving fluid to a right-sided MI will not "fluid overload" them. Do you realize how dependent the right ventricle is on preload? Do you understand how much fluid, and how fast you must give it, to cause failure? You will not increase the size of the infarct.

As an educated Paramedic...

I think we have found the problem with this one.

[Rezq304]

Responding to letsgonational. If you give NTG alone to a right sided MI, you completely knock out the preload for this patient. Incidentally, the preload is the only thing keeping blood circulating through the body because the right ventricle is the location of the infarct. A right ventricle that doesn't work means that it cannot pump blood to the pulmonary circulation for oxygenation, therefore knocking out any systemic circulation. But, in all honesty, you'll get good practice with CPR doing this. :wink:

[letsgonational]

Perhaps you all completely mis understood. "an educated paramedic?" You're all full of it...

First of all. Our cath lab DOES love us....they do perfer 4 sites (2 dual lumens)...if I have time to do it in the field, they dont have to waste time in the cath lab. Thus, this will decrease the door to open time....

We do proceed with NTG during morphine administration but dont give morphine unless they still have pain after three NTG (that was my fault in typing...misunderstanding).

We all cautiously give NTG to right sided AMI. Our goal is to make them pain free and keep their pressure above 90. If I have someone with +V4R I'm going to cautiously give NTG and be in contact with command and the cardiologist who is already viewing the 12 lead EKG to see what they want us to do. We really dont go dumping fluid into the patient...

Hope this helps clarify what I was typing out to you...

[Dustdevil]

Perhaps you all completely mis understood. "an educated paramedic?" You're all full of it...

We're "all" full of it? I have to agree with him. You haven't shown us any real evidence of education yet. Just some memorised protocols.

And, here's your sign...

[Rezq304]

We're "all" full of it? I have to agree with him. You haven't shown us any real evidence of education yet. Just some memorised protocols.

And, here's your sign...