Atypical STEMT Treatment

JwL

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Scenario:

60 y/o diabetic woman with a Chief complaint of weak, diphoretic, and nausea.
No chest pain
12 lead shows ST Elevation in the anterior leads .

Would you administer Nitro assuming BP is good ?
 

DrParasite

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Define a good BP... how is the pulse rate?

What are you giving NTG for?
 

JwL

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Define a good BP... how is the pulse rate?

What are you giving NTG for?
BP is 160/90, HR 88
Patient is a diabetic experiencing a "silent" MI.
Typical chest pn resolved using NTG is the result of restoring blood flow to an ischemic area. So, if you ID a stemi, Wouldn't the patient benefit even in the absence of chest pn?
 

Rano Pano

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I think where @DrParasite is coming from is your opening post doesn’t describe a confirmed MI. It would be in my index of suspicion, but you’ve provided a fraction of a pt assessment. Low BGL causes these symptoms. Reciprocal changes on that 12? 12 lead imposter?

If you’re saying you have a confirmed Anterior STEMI & all vitals are within a range you feel comfortable giving your STEMI meds then why wouldn’t you?
A big reason we treat pain is because of the added workload it puts on a heart that’s already oxygen deprived. NTG reduces this by decreasing preload.
 

DesertMedic66

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I think jwl is meaning more from the standpoint that the patient is having a STEMI but having no chest pain. All of my agencies that I work for only want NTG given to relieve chest pain. So if there is no chest pain then no NTG will be given.
 
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JwL

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Yes, my scenario is a confirmed STEMI. Our protocols indicate NTG for chest pain only. I was debating a co-worker regarding atypical presentations giving NTG with no pain during a Hot MI. The pain is just a symptom of the underlying issue which is ultimately why you are administering NTG. So yes, I have always administered it in the absence of pain if I have a confirmed STEMI. I was just curious if anyone else was onboard with the idea.
 

Tigger

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I thought we had established that SL NTG doesn't improve outcomes much if at all?
 

FiremanMike

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I thought we had established that SL NTG doesn't improve outcomes much if at all?
There was a block about nitro this past year at Eagles.. Some docs supported it, some docs talked about higher dosing of nitro, it was really all over the place...
 

JwL

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Why? GTN doesn't treat STEMI.

There's your answer.
Ok, so you wouldn't give NTG for chest pain if your pt was experiencing a STEMI in the prehospital setting ? As of today, we use NTG to tx chest pn. All variables aside, the question was in reference to prehospital administration of NTG for a silent MI. Reduction of preload and coronary artery dilation are the ultimate goals even in the absence if chest pn.
 

DrParasite

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I thought we had established that SL NTG doesn't improve outcomes much if at all?
Why? GTN doesn't treat STEMI.
That was what I getting at. NTG is given to relieve chest pain, however your patient is currently pain free. It doesn't "fix" the STEMI, nor does it improve patient outcomes (although, it does help to relieve the any cardiac pain the patient is feeling).

So I ask again, what is your goal when administering NTG on this STEMI who isn't having chest pain?
 

VentMonkey

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ASA anyone? As @Tigger mentions, it's substantially more beneficial in the ACS crowds than NTG. Whenever I've had these patients with atypical presentations, high cardiac-origin suspicions, and all the classic co-morbidities I'd feel much better having given the ASA in lieu of any NTG.
 

JwL

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That was what I getting at. NTG is given to relieve chest pain, however your patient is currently pain free. It doesn't "fix" the STEMI, nor does it improve patient outcomes (although, it does help to relieve the any cardiac pain the patient is feeling).

So I ask again, what is your goal when administering NTG on this STEMI who isn't having chest pain?
So again I will reiterate. The atypical present resprents the fact that diabetic woman are infamos for having silent MIs. The diabetes results in them not perceiving pn as a patient without diabetes. My point is, in the same scenario on a pt with no Hx will most likely have chest pn in the event of an MI. The diabetic pt may be experiencing the identical cardiac event with no pain. So why not tx the same? The only deterrent is you wont have a pn scale to judge effectiveness.
 

Tigger

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So again I will reiterate. The atypical present resprents the fact that diabetic woman are infamos for having silent MIs. The diabetes results in them not perceiving pn as a patient without diabetes. My point is, in the same scenario on a pt with no Hx will most likely have chest pn in the event of an MI. The diabetic pt may be experiencing the identical cardiac event with no pain. So why not tx the same? The only deterrent is you wont have a pn scale to judge effectiveness.
Because the intervention is not shown to be helpful? It's quite rare to see ACS treated with NTG in this region. Maybe if the patient was quite hypertensive and/or not responsive to fentanyl I'd consider it. But now, even "classic" STEMIs don't routinely get NTG.
 

JwL

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Because the intervention is not shown to be helpful? It's quite rare to see ACS treated with NTG in this region. Maybe if the patient was quite hypertensive and/or not responsive to fentanyl I'd consider it. But now, even "classic" STEMIs don't routinely get NTG.
Gotcha.. this is interesting ...we r in Florida and routinely give NTG for chest pn
 

RocketMedic

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Aspirin, potentially heparin or Plavix, metoprolol, maybe nitro, quick trip to cath lab
 

E tank

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Aspirin, potentially heparin or Plavix, metoprolol, maybe nitro, quick trip to cath lab
If the patient ends up having a CABG because of inability to stent from whatever reason, plavix causes a lot of avoidable problems. If there would ever be a choice, choose heparin for that reason.
 

Akulahawk

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So again I will reiterate. The atypical present resprents the fact that diabetic woman are infamos for having silent MIs. The diabetes results in them not perceiving pn as a patient without diabetes. My point is, in the same scenario on a pt with no Hx will most likely have chest pn in the event of an MI. The diabetic pt may be experiencing the identical cardiac event with no pain. So why not tx the same? The only deterrent is you wont have a pn scale to judge effectiveness.
NItroglycerin is used to treat chest pain. If there's no chest pain, what's the indication for the nitroglycerin? Given those vital signs and no other signs or symptoms that lead me to think that nitroglycerin is indicated, I would not give it. In short, if the only reason you're giving it is the STEMI on the EKG and she otherwise has zero signs or symptoms of a cardiac nature, then you're not doing her any favors. Nitroglycerin doesn't actually treat the cause of the STEMI. Same idea goes for using morphine or fentanyl. You're looking to treat the pain but neither actually treats the STEMI.

The other night, my ED sent a patient out to a Cath Lab. STEMI, confirmed by labs. The morphine and nitroglycerin we administered didn't do anything to remove the clot that was causing the ischemia. They relieved the pain, and that's their only real job in this scenario.

The kicker of it all is that about 40 minutes of time could have been saved if the EMS crew had initially taken the patient to a facility with a cath lab when their 12-lead said "STEMI" instead of bringing the patient to my facility. We're good at this... My point: Know your local system well enough that you know what the hospitals are capable of so that you can make a good destination decision and potentially save mucho time because facilities that can't do what's needed must do their EMTALA stuff, arrange for appropriate transport... stuff that takes time. Just another instance where another 10-15 minutes transport = 40-60 minutes saved from onset of sx to balloon time.
 

FiremanMike

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NItroglycerin is used to treat chest pain. If there's no chest pain, what's the indication for the nitroglycerin?
I disagree with this. Theoretically, nitro is given to vasodilate the coronary arteries to improve blood-flow to an area of the heart which is hypoxic due to a spasm or blockage. The indication for giving nitro, then, is that you feel your patient is having a an event related to hypoxic cardiac tissue.

This is why my side-bar question earlier in the thread becomes pertinent, which is "what is the actual etiology of chest pain". As of my last research on the topic, no one base been able to definitively say why hypoxic cardiac tissue leads to pain. Ultimately, this leads into why some people can be having significant cardiac events without associated chest pain.

Whether you believe nitro is helpful, harmful, or a non factor in cardiac events is a slightly different topic, although I will again mention that there are studies in both directions on this topic.
 
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