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Nitro with a right sided MI

43 posts in this topic

Posted · Report post

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?

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Posted · Report post

Did you do a V4R on this pt. IF not then it is my understanding that you cannot tell that they are having a right side MI. I was taught never to trust they writing at the top of the paper. With that BP and heart rate I would not have giving the nitro but I was not there.

Did he ever get the IV started?

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Posted · Report post

Yes, we do have V4R and no he never got a line started.

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Posted · Report post

There really is no excuse for misreading a EKG. I can understand your partner not wanting to give nitro since they couldn't establish a IV line. With a systolic pressure of 98 ( why by palpation?) I might be hesitant to administer it also. Do you not have IO access?

Your patients c/c and presentation would immediately alert me to the possibility of an MI. Sounds like your partner had a massive brain fart. Their action/non-action with this patient would have resulted in our Medical Director suspending their privileges to function until this case was reviewed by the EMS oversight committee. He does not take these sort of things lightly. Immediate remediation is required.

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Posted · Report post

I completely agree and I guess this is why I am so frustrated. This is not this first incident and I really don't think that it will be the last. I continue to get called in the office everytime a call goes wrong because I am technically the only witness. I don't want to be in the middle of it. My supervisors need to take care of it with my partner. I could write a book on all of the things that he has done wrong. I have worked with some fabulous paramedics and I am just sad that some people who call 911 for help may actually end off worse than when they call.

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Posted · Report post

So you done two ekg's on this man and sent both of them to the ER? So what level are you? Just wondering.

So he did or did not give the nitro? I am lost now. Did he give any other meds or treatments for his pt.

At your level if you know how to check for a right sided MI but not know how to read a EKG then you should take a class. It would help in the future. It also show that u have motivation to learn.

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Posted · Report post

Her original post says that the partner gave the pt a spray of nitro and off they went, with no IV access established.

I wouldn't give nitro with a BP that low and a patient looking utterly like crap... perhaps I need some more education as to nitro use however.

Would you give nitro in an unstable MI with a systolic BP above 100 for pain relief? Or would you give something else, like morphine? Why?

Wendy

CO EMT-B

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Posted · Report post

He did give one spray of nitro, but never established a line, which really made the docs happy as you can imagine. Other than the nitro, he gave some 02, 2 liters nasal. I am an EMT-B and I pretty much do everything on a call as long as it's not out of my scope of practice. I can do 12-leads, but I don't know how to read them yet. Like I said, I definately want to learn, I start a medic class next month. Basically if I don't do things, then they won't get done. I offered to do a 12-lead on a pt. with chest pain that had a heart history last week and my partner said no, I'll get it en route...45 minutes later, he never did it, just wrote his report.

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Posted · Report post

It all depends on the pt. Is the BP 102 or 110? If I have a iv then I can fix a pressure problem if needed. Both MS and Nitro are going to lower pressure.

I treat all patients separate. It is a critical thinking skill. You have to be able to look at the whole picture not just, Ok his bp is 100 or greater going to give the nitro.LOL

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I've been in the field for three years now in a rural setting and city setting and same with my partner as well. I have never seen anyone have as many problems with patient care as my partner. We took a pt. who was hypoglycemic the other day, again 45 minute transport time, sugar of 37, attempted a line...never got one so no D50 was given nor glucagen and when he gave report at the hospital, the pts. sugar was 18. I'm just frustrated because I can't fix the problem myself! I know what needs to be done, but I'm not a medic yet so my hands are tied!

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Posted · Report post

Why did you not give oral glucose. I mean you can rub a little around on gums and under tongue. that a very vascular place. SO you did do two ekg's right to check for right sided mi

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Oral glucose was given by my partner. 2+ EKG's were done....I had my husband look at them for his opinion (he is a medic) and he said that he could see the patient going from bad to worse.

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Why did you not give oral glucose. I mean you can rub a little around on gums and under tongue. that a very vascular place. SO you did do two ekg's right to check for right sided mi

Go rectal with oral glucose. Less chance of aspiration.

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Posted · Report post

Even without any cardiac monitoring at all and simply by going with your history as stated and vital signs, an inferior MI +/- RVI is reasonable.

Add to that the fact you have a 12 lead (that showed acute inferior MI) and did V4R (with ST elevation), diagnosis becomes significantly more solid.

There is this new fangled (yes I said fangled) drug called ASA. Funny enough it is actually the BEST medication that most can give prehospital for these kinds of patients. ASA actually reduces mortality, nitro (regardless of patient) and analgesics do not.

Can't get an IV? Meh, I would be quite cautious anyway with SL dosing or morphine/fentanyl. Fluids would probably be equal if not more of a concern.

ASA and oxygen with a proper history and monitoring are fine.

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Although V[sub:f9c43a1790]4[/sub:f9c43a1790]R is great, one can detect a ride side without such. Even basic XII lead interpretation along with other clinical indicators (borderline BP, Bradycardia) should be noted as red flags indicating right side, possible inferior wall involvement. Even without a XII lead, moderate blood pressure and bradycardia should have been a tale tale sign.

With other indicators, it appears this medic may have good intentions, but that itself is not enough. It appears this medic needs to be reconditioned and possibly evaluated. Maybe some refresher over AMI, etc. then if not better, fired. Sorry, give a chance then not better time to move on.

Hopefully, these physicians will make contact appropriate persons before this medic causes more harm than good.

R/r 911

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Her original post says that the partner gave the pt a spray of nitro and off they went, with no IV access established.

I wouldn't give nitro with a BP that low and a patient looking utterly like crap... perhaps I need some more education as to nitro use however.

Would you give nitro in an unstable MI with a systolic BP above 100 for pain relief? Or would you give something else, like morphine? Why?

Wendy

CO EMT-B

With right ventricle MI, giving nitro could be detrimental due to the vasoldilation reducing preload and making the heart more ischemic. Better have an IV first and be ready to challenge with volume. :lol:

I trust a member of the COE will slap me straight.

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Yeah, with a 45 minute transport it's hard to imagine not getting a line of this guy. Every indicator says Inferior/right sided MI. Borderline BP, a little brady, pale, sweaty, nausea, vomiting. The medic should have been thinking Inferior/right sided MI before the monitor was ever placed.

This patient needs treatment. For the treatment he needs a line. EJ if nothing else. Push the fluids to build the pressure you need to medicate is what I'm thinking. We need to dilate the coronary arteries, this is most likely going to be accomplished with nitrates. Push the fluids until you get your pressure, deliver the nitro, and monitor your pressure.

It seems to me, and I could be wrong, that the "Tons of fluid and no nitrates/vasodilators" rule for inferiorwall MI with right sided involvement is great in a perfect world, or for a snappy anti-intuitive response to someone new to cardiology, but I can't really make the physiology line up in my head as a hard and fast rule. In the real world this guy needs coronary perfusion. We can fudge the pressure with saline, but there's not really any pretending the hearts being perfused if it's not...right?

If time is muscle, something needs to be done to feed the pump long before the 45 minute drive to the hospital is complete...

Once again I probably should have researched this instead of pulling it out of my rear, and made some attempt to appear as at least slightly less dorkish...Yeah, well. That's never been my strong suit.

Dwayne

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Posted · Report post

People seem to be dealing very gently with this situation.

To me, he sounds like a trainwreck of a medic.

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Dwayne, I believe you are making it too hard. Think on the line of preload and after load effect. )Starling Law effect) Actually NTG is not really contraindicated but not suggested, especially when you have a presentation of such.

I agree if possible a line should have been attempted, in which I believe the poster described. I know many services have policies on how many and as well, many do not allow EJ's on conscious patients.

The difficulty of establishing a line is not really surprisingly though, bradycardia and low blood pressure ( brady producing low B/P or low ejection fraction r/t AMI). Then especially, after NTG is administered.

Something I am sure that the medic learned off, and hopefully will never do that it again.

R/r 911

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Dwayne, I believe you are making it too hard. (I'm probably looking for zebras...)Think on the line of preload and after load effect. )Starling Law effect) Actually NTG is not really contraindicated but not suggested, especially when you have a presentation of such.

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

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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.

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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.

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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.

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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

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

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