Quick Scenario For You (Students and New Medics)

RocketMedic

RocketMedic

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You're responding to a man, approximately 60, who is complaining of chest pain. The pain started 30 minutes prior, rapidly, while he was arguing with his family. The pain is described as a crushing substernal chest pressure without attendant shortness of breath. It does not radiate. It does not change with breathing, motion or palpation.

The patient's skin is normal in tone, texture and temperature. He is not sweating. Blood glucose is normal. Your physical assessment is otherwise unremarkable.

He has a history of hypertension and "stents in his heart" placed years ago. He smokes a half-pack a day and does not take any anticoagulants.

Being astute paramedics, you see fit to get a 12-lead (see attached).

What's going on, what vessel is involved, and how do you know?

What do you do?
 

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Looks like a pathologic Q wave in lead III with an elevated J point / STE and slight STE in lead II. Also appears to have some STD in I/AvL and V1 at times. My guess is distal RCA causing an RV/posterior infarct or more rarely a dominant circumflex.
 
Probably RCA.


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Admittedly gonna have to cheat on the vessel, haven't really been keeping up on that bit. (Graph from my notes says RCA).

Rest of Vitals and history. ASA. IV with some fluids. V4R and V7/V8/V9. Maybe nitro if pressure doesn't appear too soft. Not **** around on scene.
 
RocketMedic said:
You're responding to a man, approximately 60, who is complaining of chest pain. The pain started 30 minutes prior, rapidly, while he was arguing with his family. The pain is described as a crushing substernal chest pressure without attendant shortness of breath. It does not radiate. It does not change with breathing, motion or palpation.

The patient's skin is normal in tone, texture and temperature. He is not sweating. Blood glucose is normal. Your physical assessment is otherwise unremarkable.

He has a history of hypertension and "stents in his heart" placed years ago. He smokes a half-pack a day and does not take any anticoagulants.
This alone makes him a "high-risk" co-morbidity prone ACS candidate.
Being astute paramedics, you see fit to get a 12-lead (see attached).

What's going on, what vessel is involved, and how do you know?
RCA. Contiguous STE in inferior leads. Lead Ill (>) Lead ll, confirming RVI involvement.
What do you do?
SPO2 (>) 94% no need for supplemental O2, otherwise low-flow NC @ 2 lpm NC is fine for now. ASA, pain control (Fentanyl 50 titrated to relief) , bilateral IV's with one being attached to fluids time permitting, serial 12-leads, and defib pads for everyone's peace of mind.

I don't know that I am going to give any NTG given it's location, and smooth easy "code 3" to the SRC.
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Sorry, it's hard for non-new paramedics to sit, wait, and watch for new medics/ students to chime in:).
 
StCEMT said:
I mean...how many of us are there here? :p
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Lol, quite a few from what I have gathered. Where are they when you need em?*

*excluding you of course, señor.
 
VentMonkey said:
Lol, quite a few from what I have gathered. Where are they when you need em?*

*excluding you of course, señor.
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Busy mastering finding a way to be busy when called. :p

DEmedic said:
They're busy filling out FD job applications.
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That.....is probably actually an accurate statement....unfortunately, most of the places around STL that pay well are FD's. And most (not all) of the places that aren't run you into the ground and don't pay as well. The ones that do pay really well have their own set of hoops and games to deal with to get hired. Gotta eat.

But, back on track. This was a bit of a refresher since I haven't even looked at signs for a posterior infarct in a while. Feel free to drop any bits of wisdom at a later point once this gets some more responses.
 
I think we've all agreed that it's RCA.

I'd treat with bilateral IVs, ASA, NTG blood pressure permitting, fluids TKO, serial 12 leads, and a fast but smooth ride to the hospital. Pain control PRN.

Our medical director recently removed the contraindication of RVI (specifically STE in II, III, and aVF) as a contraindication to NTG.

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NPO said:
Our medical director recently removed the contraindication of RVI (specifically STE in II, III, and aVF) as a contraindication to NTG.
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I noticed that. I would still be a little hard pressed to give this patient SL NTG, especially noting it to be a preload dependent RVI.

Can you? Yeah assuming they're normotensive, then again it doesn't mean they still can't drop fast. ASA is the clear "life-saving" drug. Fentanyl being easier on their hemodynamics can help with their discomfort and distress.
 
NPO said:
Our medical director recently removed the contraindication of RVI (specifically STE in II, III, and aVF) as a contraindication to NTG.
Click to expand...

When in doubt I
VentMonkey said:
I noticed that. I would still be a little hard pressed to give this patient SL NTG, especially noting it to be a preload dependent RVI.

Can you? Yeah assuming they're normotensive, then again it doesn't mean they still can't drop fast. ASA is the clear "life-saving" drug. Fentanyl being easier on their hemodynamics can help with their discomfort and distress.
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Who says you have to give SL NTG? Start a low dose nitro drip.
 
DEmedic said:
I don't believe many ground paramedic have Tridill in their formulary or protocols.
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I did not know that, thanks. Its hard learning which local ground services have what equipment and drugs but it is important to know for when we have to type our justification for transport. I am definitely spoiled on the helicopter.
 
Most ground medics have a pretty standard load out. It may vary by one or two (or be way over the top in some areas) but it's usually pretty much the same.

It's usually limited pressors, Dope or Epi. Limited analgesic choices, Morphine and/or Fent, maybe Toradol. Limited Benzodiazepines, usually versed, maybe Ativan ot Valium. NTG tabs and paste. Plus the antiarrythmics, anti emetics and the other basics. Think "first 15 minutes" and all your gear can fit in a backpack.

Usually no pumps. Usually no vent, or a very basic vent.

Members of this forum are the exception, not the norm. The stuff we talk about here rarely makes it's way into routine EMS.
 
VentMonkey said:
I noticed that. I would still be a little hard pressed to give this patient SL NTG, especially noting it to be a preload dependent RVI.

Can you? Yeah assuming they're normotensive, then again it doesn't mean they still can't drop fast. ASA is the clear "life-saving" drug. Fentanyl being easier on their hemodynamics can help with their discomfort and distress.
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I've given NTG to inferior infarct successful a few times. Admittedly both times there was no STE in V4R

Idk that I'd call ASA the life saving drug. But with an NNT of 1:42 it's hard to argue against it lol.

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NPO said:
Idk that I'd call ASA the life saving drug.
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The NTG and Fentanyl are secondary on their list of "things to do" with STEMI alerts. Are they going to take the time to emergently set up a NTG gtt at the ED? The paste, spray, or pills perhaps more often than not, but the cause of the infarction has less to do with what NTG can, or will do to said patient vs. ASA, Plavix, Heparin, etc.

I stick by my statement, and would be hard pressed to find an EM physician not stare at you sideways for foregoing the ASA over any of the others. It really is that much more pertinent to any true ACS, so yes, life-savingz
 
ASA, IV and fluids, titrated O2; hold NTG in favor of Fentanyl.


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NPO said:
I've given NTG to inferior infarct successful a few times. Admittedly both times there was no STE in V4R

Idk that I'd call ASA the life saving drug. But with an NNT of 1:42 it's hard to argue against it lol.

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Aspirin is the only medication we give that has any marked effect on M&M in this patients. Check out the ISIS-2 study. It showed something like a 20%+ increase in survival with ASA administration.

Also, if I remember correctly fly there was a study done that showed the incidence of hypotension with NTG admin in IWMI/RVI is no worse than any other type of infarction.

http://www.jems.com/articles/print/...-effect-on-hypotension-in-stemi-patients.html



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