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Right Sided MI - How Do I Tell The Difference

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#1 spenac

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Posted 22 April 2009 - 01:53 PM

OK help a student learn the differences. Start at the basics and go deep for me. What physical differences, what EKG differences (maybe post a strip showing), what is going to differ in treatment?

No this is not homework as I have completed my Paramedic course except clinicals. I actually did a paper on this but now want more, don't want no mistakes when I'm the Paragod in charge ;) .
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#2 wrmedic82

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Posted 22 April 2009 - 02:16 PM

I think the old worn saying says it best. Treat the patient, not the monitor. Common sense is also key.
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#3 scott33

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Posted 22 April 2009 - 02:45 PM

As far as EKGs go - I read somewhere that if the ST elevation in lead III is "taller" than in lead II, you will probably have a right-sided MI. Dunno how accurate this is, but any googling of "right-sided MI" would seem to show this...

Posted Image

Edited by scott33, 22 April 2009 - 02:46 PM.

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#4 WolfmanHarris

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Posted 22 April 2009 - 03:13 PM

If 12 lead shows ST elevation in the inferior leads conduct a modified twelve lead looking for ST elevation in V4R with any two of II, III and avF. Also consider this rule of thumb, if the ST elevation is higher in lead III over lead II it is more likely that the RCA is involved over the circumflex branch (which only suuplies the inferior wall in ~20% of people).This may indicate a potential RVI or in may indicate and inferior wall MI.

In terms of clinical presentation look for JVD, or more specifically Kussmaul's sign where JVD becomes evident on inhalation. Expect hypotension due to reduced cardiac output. Expect lung sounds to be clear (pertinent negative to rule out cardiogenic shock)

Since RV AMI's occur most often due to occlusion of the right coronary artery expect that the RVI may occur in conjuction with an inferior wall MI. As such expect clinical signs of inferior MI such as nausea and vomitting due to vagal stimulation. Vagal stimulation may lead to an underlying sinus bradycardia or AV block.

Had to hit the books briefly to make sure I had the details right, but I surprised myself and remembered almost all of that. *Pat on back to self*

I think the old worn saying says it best. Treat the patient, not the monitor. Common sense is also key.

I don't follow on this at all. Common sense doesn't tell me dick about left vs right side MI. Common sense might tell me big fat guy, chain smoking with a huge cardiac history is more likely to have an AMI and keep my index of suspicion high, but this saying is for once incorrect. I cannot be sure (from my understanding) that a patient is not having a RVI without a 12 or 15 lead to rule out RV involvement. If I don't treat the monitor and jump to MONA than I'll drop their preload and potentially place the patient up a creek.

Don't confuse common sense with good, well-honed clinical judgement tempered by experience. Common sense lets us say "yep, you need a dressing for that bleedin." Clinical judgement let's us say, "these signs and symptoms suggest an MI, and the Kussmaul's sign, BP and N/V are making me think inferior or RVI. Let's take a closer look."


Edited by DocHarris, 22 April 2009 - 03:08 PM.

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#5 ERDoc



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Posted 22 April 2009 - 03:49 PM

spenac, get yourself the Garcia EKG book and make it your best friend (eat with it, pee with it, sleep with it just don't get the pages stuck together).

wrmedic, I have to disagree. I hate that saying because it is completely untrue. Your pt will not tell you, "I am having a right sided MI, you should be cautious with the nitroglycerin," but your EKG will. The pt can only describe the symptoms. It is the monitor/EKG that will give the diagnosis and guide your treatment.
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