chbare Posted December 27, 2008 Author Share Posted December 27, 2008 I think with the big push to identify RVI in patients who experience inferior wall MI, many people do not really understand what is going on and simply think that preload reducing agents are contraindicated with all inferior wall MI patients. This is in fact not the case at all, and one of the points of my scenario. We need to treat every patient differently and use our knowledge of anatomy, physiology, and pharmacology to guide our treatment. RVI is only present around 30% of the time with inferior wall MI. However, can people still have problems with blood pressure with inferior wall MI without RVI? Yes. Can people with anterior/lateral changes on the XII lead experience a right ventricular infarct? Yes, if they do not have "normal" coronary artery anatomy. so, again, we need to be flexible and look at all of these "chest pain protocols" as more of a general framework or guideline. however, we will need to take all of this into consideration when considering implementing or steering away from a specific modality. I am not telling you to ignore your guidelines; however, I hope we realize critical thinking is required to provide proper care. Again, much of this goes back to having a solid foundation of education to fall back on. Something I was told a while back continues to stick with me to this day: "people never rise to the occasion, they fall back to the level of their education and experience." What are your thoughts about using morphine on this patient? Better yet, allow me to give you the last bit of information for this scenario: An hour into the flight to Dubai, the patient settles into this rhythm: The vitals remain "stable" in the 102/66 range and the patient remains free of any complaints. What are you going to do with the rhythm? What is the rhythm? What are you going to do with the patient? Take care, chbare. Link to comment Share on other sites More sharing options...
p3medic Posted December 27, 2008 Share Posted December 27, 2008 Mobitz 1...If she isn't symptomatic, I'd leave it be. At that rate, it is likely well tolerated. I'd certainly keep an eye on things, pacer pads at the ready but for now, quite happy. Link to comment Share on other sites More sharing options...
AZCEP Posted December 27, 2008 Share Posted December 27, 2008 I'm with P3medic on this one. The heart is as stable as we can probably hope for with the rest of the situation factored in. Pushing more chemicals isn't going to be of benefit, and might make things worse. If you have Fentanyl available, it might be a better choice than morphine for pain control, but if not use what you have, obviously. Link to comment Share on other sites More sharing options...
mediccjh Posted December 27, 2008 Share Posted December 27, 2008 Excellent case!!! Everyone has already mentioned what I woulda done. Do I count as one of the older ones, with 7 years as a medic and 12 on the job? Heh. Link to comment Share on other sites More sharing options...
akflightmedic Posted December 27, 2008 Share Posted December 27, 2008 Excellent case!!! Everyone has already mentioned what I woulda done. Do I count as one of the older ones, with 7 years as a medic and 12 on the job? Heh. No. Because if you have to ask, then you are not.... Link to comment Share on other sites More sharing options...
chbare Posted December 27, 2008 Author Share Posted December 27, 2008 Strong work. Good call on the Mobitz I. This is not an unexpected conduction disturbance considering the location of the infarct. The said treatment is exactly what I did. Sometimes "benign neglect" or "babysitting" is the prudent way. The patient is "stable" at the moment, so why mess with things? Monitor and anticipate acute changes, absolutely; however, aggressive interventions may not be in the patient's best interest. Sometimes the enemy of good is better. That was one of the big points of my scenario. Always step back and really think about your interventions. Is the most aggressive intervention always the prudent route to take? This is why I emphasized the novice provider. It is easy to want to push and infuse all those cool drugs and interventions you have swimming around in your head from school; however, understanding the time and place to use these interventions is the true art and science behind our practice. Additionally, I wanted people to think about coronary anatomy and cardiac physiology and review the basics of fibrinolytics. I hope people liked this scenario. Again, I took a chance moving away from the typical chbare zebra scenario. Hopefully it paid off. On a side note; the exact scenario, patient demographics, and perhaps gender may have been changed a bit. I do not want AK calling BS on me because his boys most likely took care of the patient in question before I arrived. Take care, chbare. Link to comment Share on other sites More sharing options...
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