Inferior MI's

[volparamedic]

How many medics actually check for EKG changes on the RV4 prior to establishing an IV and giving nitro sublingual?

[IAMedic]

I will on occasion do a reverse V4, but I regularly don't do it because our protocols don't distinguish Chest Pain, so they all get the same treatment just so I can cover my own a$$. Plus, I don't feel comfortable with the whole V1, V2, V3 & V4, V5, V6 interpretations....

[RyanEMVFD]

We don't. Our protocol doesn't change either way. It's BP is above 120 then we can give nitro. Otherwise, treatment doesn't change.

[DaSharkie]

It depends on my patient's presentation as to whether I would do one.

Remember, there is a subset of the population where the RCA does not supply all of the bloodflow to the inferior wall - I forget the actual percentage.

Inferior wall MIs have a fairly "classic" presentation with the ST elevations in II, III, & aVF, hypotension, pale, cool, diaphoretic, tripoding, possible CHF, and bradycardia.

Oh yeah, a distinguished gentleman in a black robe holding a scythe. Waiting..............

[volparamedic]

The past MI's I've had inferior will usually have a drastic drop in blood pressure with RV4 changes. I'll usually have the asa chewed while attempting the IV to save myself from bottoming out the B/P and have no line. Didn't know if anyone else had experienced this.

[locomedic21]

Not me because our protocol says give nitro asa 02 and morphine for chest pain so wether or not it is inferior doesnt change my treatment except i usually start a second line and give fluids also. its wierd i guess we should have a protocol for inferior wall.

[DaSharkie]

Not me because our protocol says give nitro asa 02 and morphine for chest pain so wether or not it is inferior doesnt change my treatment except i usually start a second line and give fluids also. its wierd i guess we should have a protocol for inferior wall.

And therein lies the problem. Cookbook medicine. Unfortunately it restricts our ability to act properly and effectively in the field in the best interest of our patients. :bang: :bang: :bang: :confused: :confused: :confused: :bang: :bang: :bang:

[locomedic21]

as long as you give fluids in an inferior you are alright i wish we had a protocol for everything but our medical director is a real tool, we were the first in the state to start 12 leads in the field and that was about 7 years ago still no actual protocol to use the 12 lead that is the problem however when i call the hospital and talk to the physician online i tell them what i see like the noted elevation in leads II - III - and AVL and noted depression in leads v1-v4 tell them patients description and that im bolusing them and administering nitro asa morphine etc.... the er docs never have a problem with it we also transmit our 12-leads to the er 10 minutes before arrival so the doc can interpret it himself actually works out well. i was told in the last inferior wall Mi patient i had arrested but we revived him for a 100% save.

[BFD Medic424]

Our protocol is the same for every chest pain. Although it sort of has to be since we don't have 12-leads yet.:bang: Hopefully that will change soon.

[medic28]

We also have Life Pack 12's with the 12 lead capability, and the only "protocol" we have regarding their use is that any one with chest discomfort, or other signs and symptoms suggestive of a cardiac event must have a 12 lead done. Our protocols are very restrictive as well. ASA and NTGX3, and we have to call for morphine. Although soon with our new protocols we'll be able to give up to 4mg with out medical command. As far as when I start my IV on any chest pain patient depends on the circumstance. Our protocols allow us to administer SL NTG prior to initiation of a line, but a good example would be the lady I had the other day who had taken TEN SL NTG prior to our arrival with no relief. The SL NTG never left the bag until she had a line and 5mg of MSO4 on board.

[btroutm]

Similar situation here...our CP protocol does not distinguish, so it won't change our treatment. That being said, if we explain the situation to some ECRNs and MDs and explain why we would like to do something different, they will often agree. However, it usually isn't worth the trouble because it doesn't always work and we can get stuck debating with the hospital. I like to get reports out of the way quickly so I can focus on my patient.

[volparamedic]

I guess the whole point is not to change your care that you give with the exception of possibly giving a fluid bolus. You try to better your patient care by knowing what's going on and "do no harm"! Give a nitro to a patient with an inferior MI and RV4 changes then you have no life line and you just bottomed out the B/P. Last time I checked we're suppose to better ourselves to provide the highest quality patient care we can give. It's not any different than looking at your lead 2 for changes.

[Nicoli]

I work in the ED as a paramedic. I do field work also. I have seen what happens when you give one nitro in a patient with an Inferior MI, that is really having a right sided MI. Patient was having all the normal signs and symptoms...nausea, chest pain ( 20 on pain scale), dyspnea, diaphretic, and gray looking. Initially he was hypertensive (around 160 systolic) after one nitro...that was given 5-10 out from the hospital...he dropped to 70 systolic. Our ED medical director feels that lopressor is a better choice in these situations than nitro and/or morphine. With this patient we dumped three liters of fluid in him to get him back to 100 systolic....he also got retavase and a flight to a cath lab. The cath lab report said that he had "sludge" in his RCA.....the retavase either didn't work or didn't have enough time to work.

[brandman]

We have it clearly stated in our protocols that if there is elevation in II, III, and AvF with hypotension and bradycardia you MUST preform a V4R before TX. I like to move, not only V4, but also V5 and V6 to the right side to see how "far" to the right the infarkt is. More elevation in V6 that V4 tells you that you defenetly have a right sided infarkt.

:cool:

Do not be fooled, take the time to be sure!

[firechic]

We also have specific protocols regarding inferior MI's with right ventricular involvement and for posterior MI's.
Jeez, since my department changed medical directors, I can't remember the last time I actually gave NTG. We just don't use it that often.

[mediccjh]

We also have Life Pack 12's with the 12 lead capability, and the only "protocol" we have regarding their use is that any one with chest discomfort, or other signs and symptoms suggestive of a cardiac event must have a 12 lead done. Our protocols are very restrictive as well. ASA and NTGX3, and we have to call for morphine. Although soon with our new protocols we'll be able to give up to 4mg with out medical command. As far as when I start my IV on any chest pain patient depends on the circumstance. Our protocols allow us to administer SL NTG prior to initiation of a line, but a good example would be the lady I had the other day who had taken TEN SL NTG prior to our arrival with no relief. The SL NTG never left the bag until she had a line and 5mg of MSO4 on board.


Good to know I taught you well, Alan. You get a chocolate chip cookie.

[Medic1]

Here is where I have a problem with protocols. Where I work, our CP protocols do not distinguish between MIs with right side involement or any other type of MI. I and many of my co-workers feel that just because the protocol does not distinguish, does not mean we shouldn't. If your treamtent modality is potentially harmful, or deadly to the patient and you are doing it because the protocols say to, there is a major issue. One of the advantages to being a paramedic is the ability to think and to have the knowledge to make appropriate decisions. If you are worried about the reprecustions of going outside the protocols, don't forget we can always "pass the buck" to med control. One of the things I teach my students is medicine is not black and white. Protocols are black and white, and in order to be an effective field provider, you have to be able to work within the grey area. And as always, if you aren't sure, call med control and discuss it with them. There is nothing wrong with having to call the doc and see what they think. Just my 2 cents.

[champ]

We too have no protocol for inferior MI's, however I try to think outside the box when possible. I will almost always do a V4R following my initial 12-lead. I will establish the IV and give the ASA but if there are any question inmy mind when looking at or comparingthe 2 12-leads, I will call med control prior to administering the Nitro. I have had some doctors tell me to continue with the protocol outlined treatment and others to withhold nitro and morphine and instead gove them a Diesel bolus to the ED and monitor. For me it all depends on who the doctor is and what they think of my interpretation but if I don't call them I have to follow protocol, if I do call them I have to follow their treatment requests. Sometimes you can't win for losing especially when you really think your right and they force you in another direction.

[Medicmaster]

Personally, I have never had a person experiencing an Inferior MI experience a "jarring" drop in BP after NTG. I have had a few drop into the 90's, but nothing I couldn't fix with fluid and trendelenburg position.

Regardless, I was always taught to treat the patient "cautiously" in a right side MI. Look at BP, if it is greater than 110/P give the nitro, but be prepared to fix it. I do typically like to at least have an IV established before hand.

Not only that, but I am fortunate that we carry NTG gtts in the trucks, so I can still deliver NTG intravenously with less chance of side effects.

[CB-EMT]

Friend of mine had a chest pain call once, gets the patient in the truck, releases the engine company, just him and his partner. Run a 12-lead, looks ok. Vitals are good, little tachy if I remember correctly.

Pops the guy a nitro because he's still c/o pain, sets up for an IV. All of a sudden guy turns grey and his responsiveness takes a nosedive. Repeat 12-lead- MASSIVE inferior wall MI. "THAT wasn't there a minute ago!!!" :o

[champ]

That would absolutely, positively, and without a doubt........SUCK!!!

[BFD Medic424]

Nothing like trying to play catch-up.:D

[MedicBear14]

little redundant, yet we have the same protocol as an earlier post. we get quite reemed by the "white-shirts" if our final PCR's for an inferior injury dont have a right sided ECG...full vR1-vR6. it was a big deal a few months ago...same deal as a couple of posts ago; had a co-worker give the nitro to an injury in the inferior leads and had a monstrous drop in systolic bp altering LOC for the rest of transport.

i dont know about yall, but im not personally a fan of bringin someone in to the ER code 3 w/ an altered LOC sec. to me dropping some nitro when i could've simply done the right-sided ECG. this new standing protocol is fine with me.

:v: "Plug 'em up, Air 'em up, and Fill 'em up!" A Trauma-junkee's Creed.:v: