treatment for the brady MI

[MrSpykes]

I would give a 250ml bolus and see what it does to the pressure and if our effect is if patient responds positively but pressure still below 100 keep giving fluid until the pressure gets up high enough. But you can throw nitro out the window the inferior MI is reducing the preload and NTG is only going to enhance that. I would be looking more at the Morphine because it wont decrease prelaod as quickly as NTG. I would probably also check frequently on the lung sounds and keep dumping in fluid. Hopefully the fluid will increase preload and that will decrease the ischemia and the heart rate will pick up on its own. If it doesn't the the tissue is already infarcted.

[redwolfef6]

Definetly need to perform a V4R before other pharmacological tx.

How about starting off with 250 cc bolus NS- prime the pump. Yes I read she has light rales, but 250 shoudln't be that taxing.

Here in Denver we have to call in for Dopamine. I would ask for 5mcg/kg/min and try to get here pressure up to around 100 systolic. From there I could go down the Nitro route (barring a RVI).

[flight-lp]

This might sound a little crazy, but I had a similar experience earlier this year and after consulting our MD tried a rather unusual cocktail that despite our initial reservations actually saved our patients life.

Keep in mind the goals of an MI.........Reduce the workload (i.e. reduce SVR), maintain a perfusing MAP (>70), and at the same time, keep the heart contracting.

We started with a BP of 72P, pale crappy presentation, diaphoretic, vomiting, SOB, light rales, etc. EKG showed 4-6mm ST elevation in II, III, aVF, V7, V8, V9, and V4R. Initiated Dopamine @ 10mcg/kg/min then started Dobutamine @ 5mcg/kg/min and started a fluid bolus of 250cc. Soon our BP and MAP were acceptable and we then started low dose Nipride @ 0.2mg/kg/min. The patients HR, which was initially 42 increased to the upper 50's, the patient was pain free and looked ten times better than origianal presentation, and the BP upon arrival to the ER was 92/56 and the MAP was 74. Soon after, the Dopamine was dc'd and the Dobutamine and Nipride were continously balanced against each other until an IABP was placed in the Cath Lab. The patient subsequently underwent bypass and made a full recovery.

Interesting combo, but it worked.....................

Had a bit of pucker factor though the whole time!!!!!!

[Ridryder 911]

I have not used the Nipride with the Dopamex, and Dopamine, same effect as I described earlier. However, I am VERY cautious with Nipride drips.. 3 drops too many and bam......

R/r 911

[ffmedic9588]

Was there RVI? I would stay away from nitro even if I could have raised her BP until I knew for sure there was no RVI. Also I believe I would have went with fentanyl as it does not effect BP and HR as much as morphine does. I definitively would have done a 15 lead on this patient also what about thrombolytic therapy???

[Ridryder 911]

Remember NTG is NOT contraindicated in inferior wall AMI's however should be used CAUTIOUSLY....I too would not probably use it though on this scenario. For the thrombolytics, I would not consider it since it is an inferior wall, if it was anterior yes...Yeah, if you can the posterior wall that would be helpful too.... not many monitors allow that though, and changing leads around (forgive me Bob Page) is a booger, when your patient is going down the tubes...

R/r 911

[ffmedic9588]

Good points Rid. It has been expressed to us in ACP class if you have RVI check the posterior leads as well and doesn't take that long. I don't know I have never done it myself but I do agree 110% hard to do with such an unstable patient. Great discussion I am glad I joined this site. Awsome for school getting so many great medics and emts points of view as a studnet. Thanks guys and gals.

[Ridryder 911]

Noooooooo problem that is why we are here... to learn of each other...glad you are participating!

R/r 911

[mediccjh]

Obviously, this patient is UNSTABLE.

Atropine first, and while you have the line, if the Atropine doesn't work, go for pacing. If you have Etomidate, use it. You do not get the hypotensive effects that one would with Versed or Valium. I would get on the horn w/ the doc for guidance, since the tightrope is starting to quiver.

[medic001918]

I have to agree with others that this would be a tough case to handle. I would shy away from pharmacological intervention though as many of the medications that we carry are going to make your situation worse, not better. A right sided 12-lead would definatly be in order. And just as an FYI, there are medics in your service who have done right sided and even posterior 12-lead EKG's...myself included, but I'm not the only one. There really isn't a good reason for setting up another 12 lead on the right side and having a look to confirm what you suspect.

My first line of treatment would probably be a 250cc bolus of NS and see if the pressure responds at all to that treatment. As far as pacing/atropine, I wonder what her rate commonly is? Was she on any beta blockers that keep her rate down? Although, they don't usually keep the rate that low since it's usually around 60 BPM or so. My resting heart rate is in the 50's, even lower when I'm sleeping. I've seen quite a few elderly patients with bradycardia's as a baseline. I'd want to check into her history a little and see if maybe that's the case here. It's not likely, but don't rule anything out. I'm curious, was there any ectopy at all? PVC's? Ectopic beats? An increase in little things like that can indicate a myocardium that's becoming increasingly ischemic.

Repeat 12 leads on this call would be a must. Let's see if the infarct is increasing in size or holding it's own in size. Given the hypotension and the overall presentation of this patient, I would start looking at the possibility of cardiogenic shock. You could try to call for an order of dopamine from the hospital. My guess though due to the short transport times we have is that they wouldn't let you go with it. Otherwise, keep an eye on the lung sounds and lay some fluid on her. Maybe the fluid will help get the heart to pump a little more effectively and bring her pressure up enough that you can do something with other treatments.

It sounds like a good call to have been on.

Shane

NREMT-P