Was it an MI?

[Ridryder911]

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-_-

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]

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]

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-_-

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]

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]

There other things to look at besides ST elevation!

 

[ResTech]

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]

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]

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]

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]

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.