# Was it an MI?



## spisco85 (Apr 23, 2009)

I first responded with my volly dept. the other afternoon to a chest pain call. U/a 84 yo male complaining of chest pain radiating down left arm with a small complaint of sob. Patient stated pain was 8/10 and felt like "an elephant was sitting on his chest". Patient was diaphrotic and pale. Patient placed on 15 liters nrb and states minor relief to the sob.

History of mi and a recent cath but with no stents placed. Patient stated he had major blokage in coronary arteies. Patient denied taking any asa prior to my arrival. Patient had used prescribed Nitro inhaler three times prior to calling 911 with no relief. 
BP: 130/90
Pulse: 90
Resp: 22

I didnt have time to call med control to request permission to administer more nitro. Patient loaded into ambulance and ambulance intercepted with medic. No further information available. So is it an mi? How often will 3 sprays of nitro not dump the bp?


----------



## firecoins (Apr 23, 2009)

did you have the ability to do 12 leads?


----------



## spisco85 (Apr 23, 2009)

Nope. Bls volly service. I know without the 12 lead it is impossible to tell for sure.


----------



## Sasha (Apr 23, 2009)

spisco85 said:


> So is it an mi? How often will 3 sprays of nitro not dump the bp?



Did the nitro give him a headache?


----------



## akflightmedic (Apr 23, 2009)

spisco85 said:


> Nope. Bls volly service. I know without the 12 lead it is impossible to tell for sure.



Then why did you ask?


----------



## Scott33 (Apr 23, 2009)

Well from what you said, it does sound cardiac in nature. Pallor and diaphoresis in the absence of strenuous activity is usually a bad thing.

Do you not have the ability to give ASA?

Nitro can often "dump the BP" depending on the location of the infarct, which is why we should have a line in place prior to giving it.


----------



## daedalus (Apr 23, 2009)

"Was it an MI?"

No idea. We need 12 lead, labs including serial cardiac enzymes, and a better history physical exam than the three vital signs you listed. Other PMHx? Family history?


----------



## carpentw (Apr 23, 2009)

You need a 12 lead


----------



## irish_handgrenade (Apr 24, 2009)

was the nitro in your jump bag or did it belong to the pt?


----------



## rmellish (Apr 27, 2009)

It's possible the nitro was partially inactive. Not unusual if the tablets have been exposed to air or light for a period of time. 

Also, why no ASA?


----------



## MSDeltaFlt (Apr 27, 2009)

spisco85 said:


> I first responded with my volly dept. the other afternoon to a chest pain call. U/a 84 yo male complaining of chest pain radiating down left arm with a small complaint of sob. *Patient stated pain was 8/10 and felt like "an elephant was sitting on his chest". Patient was diaphrotic and pale*. Patient placed on 15 liters nrb and states minor relief to the sob.
> 
> *History of mi and a recent cath but with no stents placed. Patient stated he had major blokage in coronary arteries*. Patient denied taking any asa prior to my arrival. Patient had used prescribed Nitro inhaler three times prior to calling 911 with no relief.
> BP: 130/90
> ...


 
Straight up and honest with you without being condescending.  First off, you cannot confirm an AMI without either a 12 Lead and/or certain cardiac enzymes; hence the terms STEMI (St Elevation MI) and NSTEMI (Non-St Elevation MI).  All you can say is he had anginal chest pain.

Was the CP he c/o the same CP as when he had his last MI?  Or was it different?  And if so, how and to what extent?

If they had an MI in the past, they are prone to have another one.  Most people do not change their lifestyles.  If he had major blockages with no stents placed, they were probably treating him medically and he's showing evidence it ain't workin'.

Did you give any ASA?

Also, why didn't you have time to call med control?  It doesn't take long to make a phone call.  Were you feeling rushed?  If you're "b*lls-to-the-wall", you might want to slow down a bit because you're liable to miss something important.  Just FYI is all.


----------



## LAS46 (Apr 27, 2009)

> I first responded with my volly dept. the other afternoon to a chest pain call. U/a 84 yo male complaining of chest pain radiating down left arm with a small complaint of sob. Patient stated pain was 8/10 and felt like "an elephant was sitting on his chest". Patient was diaphrotic and pale. Patient placed on 15 liters nrb and states minor relief to the sob.
> 
> History of mi and a recent cath but with no stents placed. Patient stated he had major blokage in coronary arteries. Patient denied taking any asa prior to my arrival. Patient had used prescribed Nitro inhaler three times prior to calling 911 with no relief.
> BP: 130/90
> ...



One other question I would need to know is, how long ago did he take the nitro spray? was the medication expired? Did he get a severe head ache after taking the nitro? Did he take any ASA prior to your arrival? 

Question to *spisco85*:
How long was your transport time from the scene to the hospital?
Why did you not attempt to give ASA if the PT had not already recieved the max dose?

I would also need to know what the other medics did on the ALS rig to know if the questions above were taken care of... if they were not then they should have been depending on local protocol. National Registry says that you should have asked those questions that I listed above.

Dustin C.
MFR, NREMT-B Student


----------



## daedalus (Apr 27, 2009)

> One other question I would need to know is, how long ago did he take the nitro spray? was the medication expired? Did he get a severe head ache after taking the nitro? Did he take any ASA prior to your arrival?


None of these questions would help with a differential. In fact, I do not remember where, but I was reading that the use of nitro to rule in/out ischemic causes of CP doesn't even work.


----------



## Sasha (Apr 27, 2009)

daedalus said:


> None of these questions would help with a differential. In fact, I do not remember where, but I was reading that the use of nitro to rule in/out ischemic causes of CP doesn't even work.



It's still nice to know if you are giving expired nitro as nitro's got more than  just pain relief purposes. It reduces preload through vasodilationd deccreasing the workload of a hurtin' heart!


----------



## daedalus (Apr 27, 2009)

Sasha said:


> It's still nice to know if you are giving expired nitro as nitro's got more than  just pain relief purposes. It reduces preload through vasodilationd deccreasing the workload of a hurtin' heart!



Yes, but how would that question help determine if the patient is having an MI or not? The OP wanted to know if his patient was experiencing an MI vs. other forms of ACS. Asking if the nitro is expired or not, just because its some algorithm that LAS46 learned in EMT school, will do absolutely nothing in determining the cause of the pain. It is just another robotic question for the EMT to ask because they do not know what they are really doing.


----------



## irish_handgrenade (Apr 27, 2009)

daedalus said:


> It is just another robotic question for the EMT to ask because they do not know what they are really doing.


 wow...:blink:


----------



## daedalus (Apr 27, 2009)

irish_handgrenade said:


> wow...:blink:



Mean every word of it.


----------



## CAOX3 (Apr 27, 2009)

daedalus said:


> Yes, but how would that question help determine if the patient is having an MI or not? The OP wanted to know if his patient was experiencing an MI vs. other forms of ACS. Asking if the nitro is expired or not, just because its some algorithm that LAS46 learned in EMT school, will do absolutely nothing in determining the cause of the pain. It is just another robotic question for the EMT to ask because they do not know what they are really doing.



Well then please enlighten us.


----------



## Sasha (Apr 27, 2009)

daedalus said:


> Yes, but how would that question help determine if the patient is having an MI or not? The OP wanted to know if his patient was experiencing an MI vs. other forms of ACS. Asking if the nitro is expired or not, just because its some algorithm that LAS46 learned in EMT school, will do absolutely nothing in determining the cause of the pain. It is just another robotic question for the EMT to ask because they do not know what they are really doing.



Ah, sorry, I was posting from class on my phone, I misread your post :]


----------



## daedalus (Apr 27, 2009)

CAOX3 said:


> Well then please enlighten us.



Enlighten you to what? How to diagnose an MI? It was already covered here well enough by MSDeltaFlt. 12 lead and labwork, along with a H&P and family history. Sometimes a CXR and other studies are done to rule other causes of chest pain out.

Simply asking about whether or not somebody got a headache from taking nitro is not a substitute to proper education. Its a question I could teach a four year old to ask.


----------



## daedalus (Apr 27, 2009)

Sasha said:


> Ah, sorry, I was posting from class on my phone, I misread your post :]


I know you did, my comments where directed at the others here.  you need no teaching.


----------



## Mountain Res-Q (Apr 28, 2009)

daedalus said:


> Mean every word of it.



Based upon the post that prompted your comments...  good for you... needed to be said.  If I say something like that or make a joke about the an uneducated post then I get a "don't attack the uneducated" reply.


----------



## silver (Apr 28, 2009)

As far as i remember ASA isn't in every SOG in CT for basic, and needs to be approved by Medical Director and/or the state. So that might explain why it was not used. However I dont really remember right now...


----------



## spisco85 (Apr 28, 2009)

I can not give Aspirin in our current protocols.

I also did not transport the patient because I first responded.

I did not have time to call med control because the ambulance showed up on scene while I was gathering a history and vital signs.

The patient took the nitro 30 minutes before he called 911. I do not know if the meds were expired.

I ran into the ambulance crew for that day and neither bothered to actually ask the medic what was going on.


Thanks for the replies guys and gals.


----------



## Sasha (Apr 28, 2009)

spisco85 said:


> I can not give Aspirin in our current protocols.
> 
> I also did not transport the patient because I first responded.
> 
> ...




This has nothing to do with determining an MI but, if a patient takes or you give nitro, it's good to ask if they have a headache since it's one of the common side effects of taking nitro. If they didn't, the nitro could have been exposed to air or light for too long, expired, or otherwise ineffective. So next time that may be a question you can ask :]


----------



## CAOX3 (Apr 28, 2009)

Also you can ask for the burn under the tounge with sublingual administration.

Not every administration of nitro will be reflected in bood pressure readings it can also depend on the area of the infarct.


----------



## MSDeltaFlt (Apr 28, 2009)

Sasha said:


> This has nothing to do with determining an MI but, if a patient takes or you give nitro, it's good to ask if they have a headache since it's one of the common side effects of taking nitro. If they didn't, the nitro could have been exposed to air or light for too long, expired, *or otherwise ineffective*. So next time that may be a question you can ask :]


 
The operative word here, hon, is *yet*.  There are those with symptomatic chest pain that might not have any change in blood pressure or any other VS, deny HA, and still have unchanged symptomatic chest pain even after 3-4 doses of NTG that hasn't been exposed to light or air or expired or what-have-you.  The pain just might be that severe and pronounced.

I'm sure you know this.  I'm just making certain.


----------



## Tal (Apr 29, 2009)

spisco85 said:


> Nope. Bls volly service. I know without the 12 lead it is impossible to tell for sure.



I think that this kind of clinics, no matter if the pt 12 lead is clean or missing, will get the full protocol to MI. 
nitro isnt the drug of choise, aspirin and MO for the pain.


----------



## Ridryder911 (Apr 29, 2009)

Tal said:


> I think that this kind of clinics, no matter if the pt 12 lead is clean or missing, will get the full protocol to MI.
> nitro isnt the drug of choise, aspirin and MO for the pain.



Explain why? Let's see crushing chest pain, hx of coronary occlusions and apparently Angina. So when would you give the NTG?.. You would immediately give Morphine? Hmmm.. 

Do you recognize what the rationale for NTG is for and how it works as well as the dangers associated with Morphine Sulfate (as in histamine responses)?

Again, don't be led like sheep...

R/r 911


----------



## LAS46 (Apr 29, 2009)

Tal said:


> I think that this kind of clinics, no matter if the pt 12 lead is clean or missing, will get the full protocol to MI.
> nitro isnt the drug of choise, aspirin and MO for the pain.



I am really not sure what school you are going to as a Paramedic Student but you are wrong about using MO or just plain ASA for a CP Pt. If I were you I would be checking into your local protocol and also asking your instructor for information on that. Nitro can only still be used if your Pt has a RX for it and Medical Direction (depending on you local protocol) gives you the Okay to use it.

________________________________
NTG Effects:
1. Relaxes blood vessels
2. Decreases workload of heart.

Morphine Effects:
Morphine effects include but are not limited to:

    * relieves pain
    * impairment of mental and physical performance
    * relief of fear and anxiety
    * euphoria
    * decease in hunger
    * inhibiting the cough reflex
___________________________________________

I think just by looking at this, it is clearly shown that NTG would be your proper drug of choice.

Dustin C.
MFR, NREMT-B Student
BLS/ALS Stroke Assessment and Treatment Certified.


----------



## Tal (Apr 30, 2009)

Ridryder911 and LAS46

well,
the MDA protocol for chest pain that show nothing on a ECG but have the clinics of MI is:

Aspirin 200-300 mg
ECG
NTG
MO
Evac

in my post, I said that NTG isnt my drug of choise becuse of the pt B.P. in the short time that i was a first responder I saw how NTG effect quickly and drasticly on one's B.P.

I dont know how you work, I dont judge. evryone has his own methods etc. but when I treat a suspect MI pt with pains 8/10 I will give him MO to stop the pt's elephant pain, while treating the MI itself. 

agian, in other codes i will use NTG, it not a drug that I dont acknowledge, but, in this specific code I will prefer not to.

hope I made my self clear-_-


----------



## Aidey (Apr 30, 2009)

I'm not understanding why you wouldn't use Nitro in this setting. Without being able to examine the pt myself, I would say this pt is a prime candidate for nitro. 

I personally don't like the spray nitro instead of the SL pills. I've seen pts spray it in their mouths like breath spray, rather than spraying it under the tongue. 

In my protocols nitro taken PTA doesn't count towards the total dose we can give. Obviously it's BP dependant, but our MD feels that so many home nitro administrations are done with bad nitro, or taken the wrong way that we should take it with a grain of salt.


----------



## CAOX3 (Apr 30, 2009)

Aidey said:


> I'm not understanding why you wouldn't use Nitro in this setting. Without being able to examine the pt myself, I would say this pt is a prime candidate for nitro.
> 
> I personally don't like the spray nitro instead of the SL pills. I've seen pts spray it in their mouths like breath spray, rather than spraying it under the tongue.
> 
> In my protocols nitro taken PTA doesn't count towards the total dose we can give. Obviously it's BP dependant, but our MD feels that so many home nitro administrations are done with bad nitro, or taken the wrong way that we should take it with a grain of salt.



They spray it there eyes, they spray it on us.  Not liking the spray nitro.


----------



## EMTelite (Apr 30, 2009)

*sounds like*

Since this guy had, had MI's in the past then there is a good chance that this could be one although, depending on how long ago his MI's symptoms started the man should have started into cardiogenic shock which will in turn make the BP take a dump, this could be a possible case of an Angina if the attack did not happen to long ago.:unsure:


----------



## rmellish (Apr 30, 2009)

EMTelite said:


> Since this guy had, had MI's in the past then there is a good chance that this could be one although, depending on how long ago his MI's symptoms started the man should have started into cardiogenic shock which will in turn make the BP take a dump, this could be a possible case of an Angina if the attack did not happen to long ago.:unsure:



Short answer, no. An infarct will not always lead to cardiogenic shock. Depends on location and severity of the infarct. Hypertension is also common. 

Angina is merely pain. The patient *has* angina. Technically the patient is complaining of angina pectoris, as angina is a general term for pain. The question is what has provoked this episode. The main concern is that this is a cardio-respiratory issue, possibly an MI.

Welcome to the forum by the way....we're all here to learn. I know I have.


----------



## EMTelite (Apr 30, 2009)

*Thanks*

By the way thanks for the welcome... Ok so this patient is complaining of a severe chest pain which is angina pectoris... now when I am looking at an infarct why would I expect hypertension I am in no way questioning you I am just wondering where the cause of this is? Because when I have heard of a heart attack I have heard of vasodialation because the heart is trying to bring in more blood. But i have never really heard of hypertension after an MI? I have heard that Hypertension can lead to an MI but if you could give me a little insight to why hypertension would be a sign after a heart attack?


----------



## rmellish (Apr 30, 2009)

EMTelite said:


> By the way thanks for the welcome... Ok so this patient is complaining of a severe chest pain which is angina pectoris... now when I am looking at an infarct why would I expect hypertension I am in no way questioning you I am just wondering where the cause of this is? Because when I have heard of a heart attack I have heard of vasodialation because the heart is trying to bring in more blood. But i have never really heard of hypertension after an MI? I have heard that Hypertension can lead to an MI but if you could give me a little insight to why hypertension would be a sign after a heart attack?



Hypertension can be a sign of anything which stresses the body. Angina secondary to an infarct puts stress of the patient, causing hypertension. Hypertension would be more likely during an MI, rather than after the event. Hypertension alone is not enough to signify an infarct is occuring. It's certainly not that simple.

I may be treading a bit outside my understanding here, but typically hypotension presenting during an MI would be more likely to be caused by the location of the infarct (ie, anterior or inferior) affecting cardiac function, rather than an active compensation by the heart. :unsure:

 I would assume the body would attempt to increase heart rate to compensate for the decrease in cardiac output if an infarct was causing a loss of function in certain areas of the heart.


----------



## EMTelite (Apr 30, 2009)

*yeah*

Yeah now i am understanding what your saying... I was refering to hypotension during cardiogenic shock, but as you were saying for hypertension during the infarct 

Maybe I stepped out of the conversation a bit much and just assumed the patient would be going into cardiogenic shock which is obviously not the case here beacuse we have a patient with obviously decent vital signs 

But thanks now i got a little bit of a more firm look at an MI


----------



## Aidey (Apr 30, 2009)

The patient may have also had high blood pressure prior to the cardiac event happening.


----------



## EMTelite (Apr 30, 2009)

*True*

This could be the case because as said we are dealing with a patient that is 84 y/o so the possibility of High BP is very possible good point


----------



## Ridryder911 (Apr 30, 2009)

Tal said:


> Ridryder911 and LAS46
> 
> well,
> the MDA protocol for chest pain that show nothing on a ECG but have the clinics of MI is:
> ...


I hope during a code (cardiac arrest) I would use neither.

I may treating an AMI, go straight to Morphine but unless you have really determined it to be an AMI and not an AMI; then you are not treating appropriately. They patient has a hx of Angina (which is caused by lack of coronary circulation) and in fact NTG will cause dilatation of the vessels. For those that prefer NTG tab.. apparently have not administered many. I HATE them, NTG spray is the easiest to use! One can spray on the inside of the cheek (bucossa) and if you spray the eyes or miss the cheek, gums or sub-lingual, your an idiot and should not be tx patients! 

True, a usual three time dosage may rule out the differential of a unstable angina vs. an AMI. 

Again, a pressure of 130/90's is not the representation of a right side AMI or inferior wall. Yes. I would demand a XII lead before administering any medication but I believe we will see as new studies are being released Morphine is NOT as benign as we once thought it was. Many physicians do not care for the histamine response nor the increase in morbidity with those with new onset AMI's and Bifascicular blocks. 

Neither is right or wrong, as I much prefer to use Fentanyl for analgesics. 

I am concerened with blood pressures when it is associated with lateral wall involvements or lack of such in cardiogenic shock. Remembering that cerebral pressure of 60-70mm/hg and coronary refill must be at least 40mm/hg is the key. Remember as well, pulmonary hypertension and increasing work load on hypertension patients. 

R/r 911


----------



## Tal (May 1, 2009)

> Again, a pressure of 130/90's is not the representation of a right side AMI or inferior wall. Yes. I would demand a XII lead before administering any medication but I believe we will see as new studies are being released Morphine is NOT as benign as we once thought it was. Many physicians do not care for the histamine response nor the increase in morbidity with those with new onset AMI's and Bifascicular blocks.



could you link us to this new studies?


----------



## 46Young (May 13, 2009)

Tal said:


> Ridryder911 and LAS46
> 
> well,
> the MDA protocol for chest pain that show nothing on a ECG but have the clinics of MI is:
> ...



You're a paramedic student, and have hopefully completed the cardiology section, so you should be able to absorb this. Roughly 30% of inferior wall MI's based on a 12 lead are Rt sided MI's. IV access, a v4r tracing, at the least, should be admin. prior to ntg therapy. In the presence of a rt sided infarct, ntg will reduce preload, which will reduce the performance of the rt ventricle, which will lead to a significant drop in BP. In the same vein of thought, this is why a fluid challenge will be given for cardiogenic shock secondary to rt sided failure(more in, more out). This isn't the only reason, but a likely one as to why you witnessed such a drop in BP after ntg admin. Ntg is intended to stop the "elephant pain" by dilating the coronary arteries, creating a passage around an obstruction, and by reducing afterload, easing workload of the heart. Pumping against an elevated BP is like running on a steep incline treadmill. Ntg is intended to lower the speed and elevation, so you can catch your breath, and relieve the burning in your muscles from the effort. It's why ntg is a first line Tx for a suspected MI.


----------



## omak42 (May 13, 2009)

carpentw said:


> You need a 12 lead



just remember that a good majority of MIs dont present with ST elevation, so a 12 lead sometimes will be useless in determining an MI.


----------



## reaper (May 13, 2009)

There other things to look at besides ST elevation!


----------



## ResTech (May 13, 2009)

To add to the question about hypertension (HTN) with MI or ACS, HTN is commonly seen in chest pain pts for several reasons. 1) These pts have preexisting HTN due to predispositions including age and lifestyle choices over their years, and 2) Catecholamine release.... the pain response and anxiety of having chest pain causes an activation of the sympathetic nervous system which releases epinephrine and norepinephrine... these two chemicals cause increased heart rate and contractility which will increase the blood pressure.... and with an increase in blood pressure comes an overall increase in myocardial oxygen demand since the heart has to push blood against a high pressure. 

This is why analgesics are indicated for ACS/MI... for the catecholamine suppression which calms the pt thus reducing myocardial oxygen demand. Some pain meds like morphine are thought to have a duel effect of calming the pt. and also as an additional adjunct to reducing blood pressure. Although the use of morphine and its efficacy for MI/CHF is being called into question and is associated with greater mortality and higher rates of admission to ICU's. 

Nitro is the first line drug for preload/afterload reduction when dealing with ACS/MI. It will also cause dilation of the coronary arteries and ultimately a relief of pain as a result of reduced myocardial oxygen demand and improved perfusion to the heart muscle. 

Also, its important to note that pts with primary respiratory disease commonly develop cardiac disease (ie CHF and MI) as a result. This is usually a result of high pulmonary pressures (COPD) that develop which can cause cor pulmonale or dilation of the right ventricle. So, these pts also will have HTN to start with. Im going a little too far (have to stop myself.. ha ha) but hope this explains some of the incidence of HTN in the presence of ACS.


----------



## omak42 (May 15, 2009)

reaper said:


> There other things to look at besides ST elevation!



very true.....sorry I didnt go into any depth i just pointed out the one thing that most people look for right away.....at any rate my point still remains valid that you cant always rely on EKG changes because there are still quite a few out there that dont present with major EKG changes.  its just a piece of a puzzle.......not always a reliable diagnosing tool


----------



## HotelCo (May 15, 2009)

omak42 said:


> very true.....sorry I didnt go into any depth i just pointed out the one thing that most people look for right away.....at any rate my point still remains valid that you cant always rely on EKG changes because there are still quite a few out there that dont present with major EKG changes.  its just a piece of a puzzle.......not always a reliable diagnosing tool



Well, along with the patient's presentation, history, vital signs, and their EKG. That's pretty much all we have to go by. Can't run troponin levels in the ambulance yet.


----------



## omak42 (May 15, 2009)

HotelCo said:


> Well, along with the patient's presentation, history, vital signs, and their EKG. That's pretty much all we have to go by. Can't run troponin levels in the ambulance yet.



Im aware of that.  And I didnt say that an EKG was useless....I said it was another piece of the puzzle just like you stated.  However if you read my post it was about the fact that people keep saying that you NEED an EKG to diagnose an MI, but that isnt true because if it doesnt show any changes then it isnt going to doing anything for you.  Just like we all hear treat the patient not the machine.....but it does come in handy for sure


----------



## Kookaburra (May 19, 2009)

daedalus said:


> None of these questions would help with a differential. In fact, I do not remember where, but I was reading that the use of nitro to rule in/out ischemic causes of CP doesn't even work.



Just jumping in to give a personal anecdote about this from when I was a patient - I went to the ER for pericarditis my senior year of college, and the doc gave me a nitro patch - helped the pain and I went to sleep like a baby (I hadn't been able to sleep for 2 days b/c of the pain). So, yeah. Obviously I wasn't having an MI (I thought I was at the time, oh lordy I never want to go through that again), but NTG gave me relief. And I had no headache or anything. (or if I did, I didn't notice) No idea why it helped, maybe when I get into medic school I'll find out.


----------

