Reciprocal ECG changes???

[VirginiaEMT]

Did V1 - V3 also have a large R wave? Sounds your man was having a major multi-vessel disease process. Definitely Inf, Lat, and possibly posterior as well. One sick dude.[/QUOTE]



I have attached the strip, I think!!

 

[Christopher]

That is known as a frank STEMI. Remember in inferior MI's you will nearly always have ST-D in aVL.

Inferiorposteriolateral...proximal RCA (ST-E in III > II) would be my guess. It doesn't appear to have the "signs" of a concurrent RVI (no ST-E in V1) but without V4R you don't necessarily know for sure. His BP is borderline, so I'd lean on assuming RVI and holding off on NTG until I had fluid rolling.

 

[systemet]

ANY CRITQUE OR ADVICE WOULD DEFINITELY BE APPRECIATED!!!!

I think you treated appropriately. Critical actions as I see it are:

(1) Recognise STEMI on ECG
(2) Give ASA
(3) Initiate / expedite reperfusion therapy
(4) Be aware of the potential for sudden complete heart block or VF/VT

Things to do differently / extra?

- Obtain a 15-lead of V4R to screen for RVI; if elevation is present absolutely withhold NTG.

- plavix / enoxaparin

- perhaps some fentanyl for the pain

- more IV access

- consider antiemetic

 

[Scott33]

If the Inferior side of the heart is supplied by the RCA and the lateral the LAD or Lcx doesnt that mean that this person is having 2 x infarcts simultaneously? how is this possible?

Really bad luck? Multiple emboli from a spontaneously converted a-fib in someone who isn't med complaint?

I honestly don't know, more guessing than anything.

It seems like it would be Lcx rather than LAD but depression in aVL and elevation in V5-V6 makes me think it might be the LAD. I'm somewhat confused about it. Especially with V-4 having no changes.

Unfortunately I don't have the greatest knowledge of the circulation of the heart other than major vessels.

The patient probably has a left dominant coronary artery. A proximal occlusion at the LCx will affect the inferior, lateral, and posterior walls.

 

[VirginiaEMT]

What would be the relevance of knowing where the occlusion is located, other that right-sided? I know it's good information and I want to be as intelligent as I can be on the subject, but how does location effect treatment in the field?

 

[Christopher]

What would be the relevance of knowing where the occlusion is located, other that right-sided? I know it's good information and I want to be as intelligent as I can be on the subject, but how does location effect treatment in the field?

If you have an idea of the infarct related artery, you can potentially see into the future and predict problems. 'Cause knowledge is power!

RCA? Bradyarrhythmias, AV nodal blocks, RVI (preload dependent hypotension).
LCX? Subtle signs on the surface ECG, often mislabled "NSTEMI".
LAD? CHF/Pulmonary edema, tachyarrhythmias, left-sided cardiogenic shock.
LMCA? Sudden cardiac arrest, intractable arrhythmias, left-sided cardiogenic shock.

So in this case with sinus bradycardia, 1AVB, and a likely proximal-RCA occlusion we should be highly suspicious for the development of higher degree AV blocks and subsequent hypoperfusion. Fluids, atropine, and/or pacing may all end up being required.

Knowing the sequelae can enable you to be a proactive provider rather than a reactive provider.

 

[Brandon O]

LMCA? Sudden cardiac arrest, intractable arrhythmias, left-sided cardiogenic shock.

Also importantly, that these patients generally do not benefit from thrombolytics -- so they, even more so than your other ACS patients, absolutely require transport to a facility that can perform PCI and/or CABG.