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ECG Challenge: Nitroglycerin, right?

EMS1.com News

February 06, 2013


EMS 12-Lead
by Tom Bouthillet

ECG Challenge: Nitroglycerin, right?

To give or not to give, that is the question

By Tom Bouthillet

Editor's note: Check out this month's ECG case study and submit your treatment plan in the comments below. If Tom selects your plan as the best, you could win an EMS1 T-shirt and bottle opener. Good luck!

EMS is called to the residence of a 67-year-old male complaining of shortness of breath.

At the time of EMS arrival the patient walks out of the bedroom into the living room and slumps over onto the gurney in obvious distress.

Past medical history: Hypertension, GERD, Prostate CA
Medications: Prinivil (lisinopril), Norvasc (amlodipine), Prevacid (lansoprazole)

The patient appears anxious. His skin is dusky and diaphoretic.

He states that he was short of breath "on and off" all night and had planned on playing tennis in the morning but "felt way too bad."

Vital signs are assessed.

  • RR: 18
  • HR: 34
  • NIBP: 108/50
  • SpO2: 97

The patient states that he became "much worse" after ambulating from the bedroom to the living room. As he calms down his respiratory rate comes down to about 28.

Breath sounds: diminished bilaterally

The patient is placed on oxygen via NRB mask @ 15 LPM as the cardiac monitor is attached.
 

A 12-lead ECG is obtained.

What is the heart rhythm?

What do you think of the 12-lead ECG?

Would you activate the cardiac cath lab?

How would you treat this patient?
 

About the author


Tom Bouthillet is a Fire Captain/Paramedic with Hilton Head Island Fire & Rescue, Editor of the EMS 12-Lead blog, host of the Code STEMI web series at First Responders Network, a member of the Editoral Advisory Board of EMS World Magazine, and developer of the 12-Lead ECG Challenge smartphone app. He has taught nationally in the Critical Care Transport (CCEMT-P) program out of UMBC and his writings have been referenced in the American Heart Journal, the Journal of the American College of Cardiology: Cardiovascular Interventions and the EP Lab Digest. Contact Tom at tom.bouthillet@ems1.com.
Comments
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Gordon McDermid Gordon McDermid Thursday, February 07, 2013 5:46:09 PM O2 NC 4 lpm. Transport to the nearest Interventional Cardiac Facility. STEMI Alert - Inferior Wall MI with 2, 3 & AVF and reciprocal changes shown in the V-leads. V4R Evaluation - if positive withhold nitrates. Atropine.5mg IV, repeat prn to a max of 3mg. If S/S aren't present for CHF, Fluid challenge 300cc. If unsuccessful, TCP (with available sedation).
Charles Faulkner Charles Faulkner Thursday, February 07, 2013 5:59:15 PM Not that hot on the rest of it, but the little understanding I do have - I would take a shot on the rhythm as AV Junctional Bradycardia... maybe I should do some training :)
Jimmy Futrelle Jimmy Futrelle Thursday, February 07, 2013 6:12:21 PM This is a third degree heart block. The ventricular escape rhythm can easily mimic ST elevation MI. The bradycardia needs to be treated before you can get an accurate estimate of the patient's cardiac status. Nasal oxygen at 4-6 lpm. Atropine can be administered. Have pacing immediately available though and be prepared to use it. Don't forget the pain meds if you place. It hurts like he'll. Once you get the rate under control, you may well see no indication of an inferior MI. Get a thorough history. Find the possible cause of the block. This patient need the cause fixed or a pacemaker inserted.
Milly Howatson Milly Howatson Thursday, February 07, 2013 6:15:39 PM Load and Go to facility with cath lab. Treat EN route. 100% O2 15lpm. Establish IV line. Fluid challenge provided patient not got pulmonary oedema. Nitrate not even in the running patient too bradycardic and Inferior MI. Consider IV Morphine low dose. Atropine as per protocols. Adrenaline IV titrated in 1 litre NaCl 0.9% administer as required for bradycardia. As per New Zealand standards.
Katie Moon Katie Moon Thursday, February 07, 2013 6:53:26 PM Not an expert but it looks like sinus brady with a 1st degree block and inferior MI with reciprocal changes noted to 1 and avl.i would withold ntg and start bilat iv's with pacing pads in place and definitely give the cath lab a heads up.treatment would obviously start with o2 and ASA PO.monitor pt condition enroute and treat symptoms as they warrant.At this time he is perfusing ok and pacing would not be first on my list, but it would stay there.I would consider Atropine, however it seems that would possibly speed up an infarct.
Ali Hardani Ali Hardani Thursday, February 07, 2013 11:03:01 PM complet heart block.inferior mi.cardiac cath lab.
Hadi Pourshanbeh Hadi Pourshanbeh Thursday, February 07, 2013 11:57:28 PM heart block, hiss bandle escape, inf.MI, need cardiac peac maker, fluid replacement anti coagulant , sedation with attention to NIBP&PCI , WITH attention to condition CABG.
René Verbeek René Verbeek Friday, February 08, 2013 3:34:47 AM Inferoposterior MI with complete heartblock (junctional escape rythm). Go for PCI! No nitrate.No oxygen (in ACS aim for O2-sat 94-98%, do not hyperoxygenate). Give Aspirine, titrate morfine, consider fluids.
Jeanette van Oijen Jeanette van Oijen Friday, February 08, 2013 3:44:00 AM Dat wou ik nou net zeggen...
Brian Schlener Brian Schlener Friday, February 08, 2013 3:48:00 AM It's an inferior stemi with a 3rd degree block underlying with a junctional escape.. not ventricular escape.. it's not a stemi mimic, there's reciprocal changes in lateral or septal leads. I'd also do a 15 for suspecion on right sided involvement. O2, asa, nss. No nitro. To pace or not to pace is the question. I'd pace it, but call medical command first.
Jason Hussein Askelini Jason Hussein Askelini Friday, February 08, 2013 4:01:34 AM Good lord, no. STEMI, inferior.
Roger Gerholt Roger Gerholt Friday, February 08, 2013 4:02:00 AM 3rd degree AV block. Inferior MI pattern. Consider right side involvement and withhold nitro. Cardiac alert activation. Pt is typically hypertensive so I would consider his BP marginal. ASA and judicious fluid. Fentanyl for chest pain. Atropine may work due to narrow QRS indicating higher AV node block.
Jonathan Farrow Jonathan Farrow Friday, February 08, 2013 4:21:54 AM I know I'm going to end up being "That Guy" with my answer, I'm leaning away from MI, agree that there is a 3 AVB, but with rate and pressure I'm feeling like there is a V/Q mismatch. I would get 2 lines, but I would be careful with my fluids, pressure isn't holding well and albumin can only maintain so much osmotic pressure. I would hate to have this guy but I would start considering dopamine, his diastolic is crappy and coronary perfusion is diastolic driven, if there is a clot there isn't going to be enough pressure to get blood around it. Would give ASA and Plavix prophylactically based on the poor perfusion and possibility of reperfusion arrhythmias. If his pressure starts coming up and an MI becomes apparent would consider Nitroprusside infusion to increase coronary circulation. Then I would try to pull the seat out of my very clenched rear end.
Jonathan Farrow Jonathan Farrow Friday, February 08, 2013 4:30:25 AM As a side note I would notify the cath lab, but more so that the PT will probably need an IABP and a Pacemaker
Erica Racedo Erica Racedo Friday, February 08, 2013 4:56:25 AM I agree with Brian Schlener, except I would consider Nitro after the 15 lead and consult with medical command. Some MD's like to pre-med with NSS bolus before Nirto in these cases, so it all depends on your Med Command.
James Oswald James Oswald Friday, February 08, 2013 5:45:43 AM Junctional/maybe a little lower escape rhythm with 3rd degree block. Inferior-posterior MI with reciprocal changes. No oxygen. Aspirin. Wouldn't even let this guy look at a bottle of nitro. Small doses of morphine or fent. Look at his JVP, mucousa, skin turgour, tongue, tibia, fluid input/ouput; maybe maybe consider optimizing his volume status with some super cautious NS aliquots. What he needs is anything that expedites a patent coronary artery; all the rest is ancillary.
Victor Madison Victor Madison Friday, February 08, 2013 6:07:24 AM 3rd degree av block, shows inferior STEMI with reciprical, however would not activate cath lab. I would advise cardiac facility what I have. Continue this pt on 15l/m high flow oxygen. Immediate TC Pacing at 70bpm rate. Valium iv for pn/with monitor of bp. No nitro.
Nabil Ramdani Nabil Ramdani Friday, February 08, 2013 7:56:50 AM this is inf stemi obvios withe miror st depression copmlicated with coplete auriculoventriculair bloc probably by vagal irritation try atrpine firt then pacing or isuprel since there is no hypotension or may be there is if choc signs are here if hemodinamic stable and less then 3hours fibrinolyse can be tried or better pci'see below!) in addition to vantithrmbotique treatment. below ":)! : I think there severe hypotension because normaly in high degree AVB III there hypertension so 108 mmhg is very low we have to check jug veive and right ventricul signes extesion or better echocardiographie.
Norm Bernstein Norm Bernstein Friday, February 08, 2013 3:33:19 PM Looks like a third degree blo k except for the narrowQRS. I would pass on the nitro in pre-hospital. May be an inferior mi, my be a right sided mi.
Simon Briggs Simon Briggs Friday, February 08, 2013 3:53:22 PM NZ procedures say Reservoir mask is reserved for severe hypoxia. Otherwise the simplest device and lowest flow rate to achieve the desired SPO2 level. Just wondering as I'm BLS in Christchurch.
Daniel S. Syme Daniel S. Syme Friday, February 08, 2013 4:09:02 PM Complete heart block. Inferior STEMI maybe some lateral wall involvement. Definately activate the cath lab. 324 mg of ASA PO STAT. Atropine and be prepared to pace if his b/p drops. Follow-up 12 lead when in his heart rate comes back up. No O2 as long as his SpO2 is over 94%. No NTG. L&S to the nearest heart center.
Troy Hoover Troy Hoover Friday, February 08, 2013 4:14:04 PM Junctional bradycardia with a complete HB. 12 lead shows an inferioposterior MI with RVI (STE III>II). First things first, fast patches on! Yes, theoretically atropine should work due to the vagal innervation on this supraventricular escape but it could also possibly worsten the MI by increasing the oxygen demand. Pacing (in my opinion) is much more reliable on complete HB's. Titrate oxygen to 94-98%, 324mg ASA and bilateral IV.Transmit 12 and activate cath lab. There are two reasons why I would not give NTG or MS; 1) patients with RVI are preload dependent. Vasodilation can result in detrimental hypotension that could be hard to reverse. 2) the patient is in a complete HB. He can't increase his heart rate to compensate for hypotension. If it was me I'd stick with fentanyl and a judicious fluid bolus to help assist the right ventricle.
Casey Cardwell Casey Cardwell Friday, February 08, 2013 4:51:09 PM I agree with much of what's already been said, but I would add that the STE is greatest in LIII, adding more concern for this being an RVI, making NTG a more risky intervention. NTG doesn't save lives, ASA and cath labs do.
Anna Werner Anna Werner Friday, February 08, 2013 4:54:22 PM I'm a kiwi too, but would do things differently. The patient has a complete heart block, with inferior MI - strongly suspicious of RVMI and would do V4R to confirm. GTN contraindicated due to rate, and hypotension. Pads on, pacing with fentanyl for analgesia, saline fluid challenge. if pacing didn't work I've got the option of adrenaline infusion (poor mans dopamine), but I don't think atropine would work for CHB. O2 absolutely, titrate to keep SpO2 above 94% so probably an acute mask initially. LATER - load and treat en route, Cath lab if available. early notification of ED absolutely.
Sarah Werner Sarah Werner Friday, February 08, 2013 4:56:48 PM Darn it, daughter was logged onto FB, she hasn't got a clue about this stuff, should have been my reply!
Blake Bradley Blake Bradley Friday, February 08, 2013 6:03:23 PM CHB...02, IV, NSS, apply pacer pads, admin 0.5mg atropine rapid IVP which may not work since its a high degree block so hit him with some versed and pace away. txp to closest facility.
Jeff Kramer Jeff Kramer Friday, February 08, 2013 11:36:19 PM It's an inferior MI. It's also a third degree block. There are reciprocal changes in leads 1, and aVL which confirms the inferior MI. I'm confused as to whether this would originate in the ventricles because the rate is less than 40 (which suggests ventricles) but the QRS isn't wide (which would also suggest ventricles). It's usually junctional during a third degree heart block and usually the rate is above 40 (in this case it isn't) and usually the complexes are narrow (in this case they ARE narrow). So it's suggestive of being both ventricular and junctional. A junctional bradycardia can have a rate slower than 40 bpm but you usually have inverted p waves in II, III, and aVF. In this case we don't. I would probably be cautious and assume it's ventricular based on rate and lack of inverted p waves...although ventricular rates usually suggest anterior MI's and junctional rates usually suggest inferior MI's which is another reason I'm not sure. This EKG suggests inferior but to be safe I would do another 12 lead (probably several more if possible) and also check out the 15 lead and see if there are reciprocal changes in v7, v8, v9 which would suggest the anterior MI. I would definitely ask for help from my medical control and transmit my 12 leads to the ER. I would also follow my standing orders for MI and my ACLS standing orders for the bradycardia. The patient is definitely in need of a pacemaker. If I had to guess right now I would say inferior and anterior MI from a block above the Bundle of His that progressed from a first degree block or second degree type I and then progressed to a third degree. I would maintain a patent airway, assist breathing as needed. I would NOT give O2 since the sat is above 94 percent (that's how my orders are written and it's based on a study from Wash U School of Medicine). I would transport to the nearest STEMI center and call ahead to activate the team. I would begin pacing immediately while someone helps establish an IV. I would sedate the patient via the IV. I would want another IV via the AC for the cath lab. I would draw up atropine.5mg in case the patient becomes symptomatic after I pace him (up to 3mg in doses of.5mg). I would consider administering IV dopamine 5 mcg/kg/min if atropine wasn't effective after the second dose. I would also give nitro.4mg sublingually every ten minutes while monitoring BP (if the patient has had nitro before). I wouldn't give nitro if he hasn't had nitro before because his pressure is below 120 (also standing order). I would administer ASA 324mg as long as it isn't contraindicated. If his pain persists I would give fentanyl via IV 1mcg per kg slowly over 3-5 minutes.
Phillip Wright Phillip Wright Saturday, February 09, 2013 5:56:04 AM This is a Complete Heart Block (junctional), immediate pacing pad placement. Caution using them though, only if patient condition worsens, could make MI worse. I realize there is no mention of "cardiac" in the dispatch info, but shortness of breath, in my opinion, should be highly suspect of cardiac issues unless there are known issues with respiratory which still should receive monitoring. His meds would reinforce that suspicion. His skin is dusky and diaphoretic, also cardiac indicators. 12 lead first. Otherwise the oxygen therapy could "fix" the problem (probably not in this case) without finding the cause. ASA -324mg as long as no allergies, BP, pulse oximetery, establish IV x2. 12 lead shows inferior MI with some anterior involvement. Reciprocal changes in I, avL, V1 and V2. Right-sided 12 lead to check for right sided involvement. Maintain O2 sat above 95%. With diminished lung sounds, could be left sided heart failure, which in turn causes right sided heart failure. Activate cath lab for STEMI alert. Patient has extreme bradycardia (symptomatic), possible right sided involvement - would not recommend NTG. NO atropine! increases myocardial oxygen demand and probably wont be effective in CHB. Load and go. Monitor patient very closely. Treat the patient, not the monitor. The patient will determine the course of action.
Shannon Tinker Shannon Tinker Saturday, February 09, 2013 11:27:34 AM I have actually had this call. IMI with s/s of right side involvement. Cath Lab activation, O2 to maintain sat, ASA, 2 lines. V4R, fluid bolus. No Nitro - RVI patient already with compromised preload. Nitro reduces preload further. BP <90, start dopamine 3-5mc/kg/min. Ventricular pacing considered but provides no significant benefit in AV disassociation for the MI patient with RVI. To cath lab for PCI. The one I ran was in cath lab 11 minutes after ED arrival - 100% occluded RCA - cathed discharged to home couple days later.
Dru Ross Dru Ross Saturday, February 09, 2013 12:15:28 PM Third degree heart block. This does not rule out inferior/posterior MI. Run posterior leads for confirmation. Give o2 only if SPo2 is below 95%, ASA if patient has not already done so, and withhold nitro due to the possibility of the inferior MI. Atropine is not indicated due to the high grade block and will be ineffective in treatment. Proceed directly to TCP. Patient should receive Fentanyl for pain control instead of Morphine and Valium or Ativan for light sedation if needed. I would hold off on the fluid challenge as you may have fluid overload if TCP works. No Dopamine for this patient either as this will add undue strain on the cardiac muscle. Call PCI center and activate code STEMI. Patient goes directly to cath lab and you get a pat on the back from a thankful cardiologist.
Saturday, February 09, 2013 12:16:15 PM Third degree heart block. Inferior MI, possible Rt side MI do right side 12 lead or move v4 to rt position to confirm. Check lungs sounds and if clear start iv and administer NS fluid bolus, continue to monitor lung sounds. Apply pacer pads. Check BGL. Get more history about patients medication regimen and when meds last taken. 15lpm not appropriate with sats of 97% - maintain sats 95 -99 with O2 as needed. Do NOT administer nitroglyerin or morphine. Patient is on Norvasc - consider calcium channel blocker toxicity which can precipitate 3rd degree block, if strongly suspected or present administer calcium and/or glucagon. If NS fluid bolus does not improve patient, if unable to administer fluid due to pulmonary edema, and if tx for Ca channel toxicity does not resolve promptly then pace the pt and pace immediately at any time that pt condition deteriorates. Activate the cath lab on way to hospital and notify them of findings and treatment.
Dustin Williams Dustin Williams Saturday, February 09, 2013 12:37:54 PM The pt has a 3rd degree heart block so for everyone that is considering atropine you should reconsider. There is an inferior MI present with possible right sided involvement preform a v4r to rule it out. ASA, o2 15L. The pt is unstable and bradycardic place pacer pads for pacing. Consider versed with caution do to low bp but do not delay pacing. Two large bore IVs at least 18g. Do not withhold nitro because of a possible positive v4r. If you service uses paste it's a good option because if the pt's bp drops you can simply wipe it off. Morphine for pain and zofran for nausea/vomiting. Fluids wide open. If unable to maintain BP consider dopamine.
Anna Golz Montgomery Thomas Anna Golz Montgomery Thomas Saturday, February 09, 2013 12:47:13 PM heart block , inferior MI alert cath lab, O2 IV fluids, ASA pace? pt is symptomic,? minor sedation before pacer to avoid increased stress,? nitro due to BP being hypotensive for pt,
Nathan McManus Nathan McManus Saturday, February 09, 2013 1:31:07 PM Sinus Brady with 3rd Degree Heart Block. Inferior wall MI (II, III, AvF elevation) and Septial wall injury (V1 and V2 depression). With that I believe there’re 3 issues here, first is STEMI, second is CHF and third is Complete Heart Block. I feel this patient is well on his way to cardiogenic shock. I think he is in CHF evident due to S/S sweaty, diminished lung sounds and SOB all night (right side heart failure take longer because it has to back up through the body before it gets to lungs). Treatment would be to back down O2 to just maintain 94% SaO2 or above (due to findings in recent studies), ASA, I would give Nitro but for all that don’t agree, contact medical control for guidance, Pads attached, IV lines with NaCl and Dopamine. The reason I would go Dopamine instead of Atropine or TCP is as follows. Although AHA does say it’s ok to give Atropine in 3rd Degree Heart Block, it also advises to use caution in the presence of MI with any Brady Rhythm. Also we all know AHA put that in there because most nurses and doctor can’t tell the difference between any of the Heart Blocks….Just kidding. So why Dopamine, well AHA ACLS 2012 does say that Dopamine is just as effective in Brady Rhythms as TCP. Plus Dopamine is the drug of choice for cardiogenic shock, which I believe he is well on his way to. I feel this treatment would allow me to now concentrate on patients MI. I would alert STEMI team and hall balls!
Kristi Roberts Moore Kristi Roberts Moore Saturday, February 09, 2013 1:49:58 PM Its deff 3rd deg heart block with an inferior MI, however there is no such thing as a stable 3deg heart block. Pacing is a must. Deff need to do a v4R and see if there is rt side involvement to see if nitro can be given. Give the ASA and pace. Deff Call a STEMI and send EKG to EC. Have fluid hanging but be judicious listenting to lung sounds and checking for any changes in EKG during transport. The Cath Lab will except pts currently being paced.
Sean Vesak Sean Vesak Saturday, February 09, 2013 6:37:48 PM Right Ventricular Infarct with posterior involvement, he has more elevation in lead III than II, making this indicative of right sided involvement, also depression in V1-2 that are reciprocal changes also indicative of posterior involvement; 15-Lead should be done to confirm. 3rd degree block, however I don't agree that this is symptomatic yet due to BP being 108/50... his symptoms are likely due to the fact that he's having a big jammer. The 3rd degree block though is due to the RVI, his conduction system is completely stressed right now. Tx:(a lot of this will be happening concurrently during transport). 1. ASA 160-320mg 2. Nasal Cannula with EtCO2, he doesn't need O2 at this moment as his SpO2 is >94%. The EtCO2 gives us realtime breathing status, as well as cardiac status, if his CO2 plumets.. we have a big problem as his cardiac output just tanked. 3. Pacer pads should be on, however I wouldn't start pacing him just yet, he has a pressure, no need to stress the heart further at this moment. 4. Big Mother IVs, but lets be careful with our fluid. Yes RVIs are preload dependent, and he needs preload to live, but he does have preload right now because he has a pressure. 5. 12/15 Lead trasmitted to our cardiologist, he will be determining if I'm giving this guy lytic, taking him to the cath lab, or doing both. 6. Fentanyl 25mcg PRN for pain. Fentanyl has less affect on preload. Nitro spray is completely contraindicated, giving this guy 400mcg of Nitro all at once is going to dump his preload and potentially cause him to code. I would only consider IV nitro starting at 20mcg/min... and to be honest, due to proximity of the cardiac centers where I work, this likely won't be happening. 7. Depending on the cardiologist, and depending on if we're going to the cathlab or giving this guy TNK will determine if I give him Clopidogrel 300mg or Ticagrelor 180mg. 8. Enoxaparin 1mg/kg SQ, and if we're giving TNK, then also Enoxaparin 30mg IV. 9. If I get the go-ahead (unlikely in this patient because he is a complicated RVI with 3rd degree block), then I'll give him a weight based dose of TNK. 10. Now I'm not going to give him dopamine just yet, again because he has a BP. I'd much rather give this pt norepi instead if his BP dropped. The dope at low dosages is going to give us Beta1 effects at low end dosing, which is going to cause increased cardiac workload, thus increasing myocardial ischemia and likely increase our infarct size, now if you don't have levo, then you kinda have no choice if this guy's pressure drops and is unresponsive to fluid (of course balancing this with the concern of pulmonary edema and drowning him). The Levo/norepi is going to give us Alpha 1 effects with the low end dosing, so we will get our pre-load back quickly without having to stress the hell out of this guys heart. I would go this route before pacing him. Just got a call, so cheers!
Tammy Lalonde Tammy Lalonde Sunday, February 10, 2013 1:28:05 AM Wow Smartypants! :)
Samantha Bruce Samantha Bruce Sunday, February 10, 2013 3:56:07 AM The P wave march out, QRS is regular but ventricular rate. This is a 3rd degree block. This is not an activation for the cardiac cath lab because this person needs a pacer. Can consider Atropine under medical direction. Start a line, taking labs.and run IV fluids but not KVO. Monitor for difficulty breathing, consider a NRB at 10-15LPM. I would also administer ASA, maybe see about giving Ativan to facilitate external pacing. Rapid Transport to the nearest appropriate hospital with cardiac capabilities. Transmit to the hospital the 12-lead ECG.
Linda Kuban Linda Kuban Sunday, February 10, 2013 5:39:35 AM O2 nasel, request to give ASA (still in a "mother may I" state) transmit the ECG to hospital, Def medic intercept and I would error on the side of safety and do stemi alert. I would say possible 3rd degree block, and MI Run fluids but monitor lung sounds closely.
Andrew Rork Andrew Rork Sunday, February 10, 2013 2:45:02 PM Hey, just a comment on people's oxygen administration decisions. Oxygen is ALSO delivered to cells by being dissolved in the plasma. This can be beneficial in AMI/ CVA patients even though "maximum" hemoglobin binding has happened. More research is occurring in this area for future AHA guidelines.
Jeff Kramer Jeff Kramer Sunday, February 10, 2013 3:38:34 PM I agree with the people about being suspicious of posterior and rvMI. I feel we need more information to determine if it is any of the following (and we should be suspicious of all of them): anterior, posterior, and rvmi. If we have a 15 lead we should look to confirm reciprical changes for anterior MI and to confirm a posterior MI. We should switch to the right side 12 lead to determine rvMI. I know there is some depression and yes we should be suspicious. If there is evidence of an rvMI we shouldn't give nitro.
Doug Harwood Doug Harwood Sunday, February 10, 2013 9:43:15 PM 3rd degree heart block. Inferior stemi with possible posterior involvement. Do a V4R and V7 V8 V9. Transmit and activate cath lab. IV, O2 (2 lpm NC) and therapy pads for possible pacing and resus if required. Although I doubt it's effectiveness in a third degree block, atropine to increase heart rate or more likely sedation and pacing if patients pressure drops. I would be hesitant to use nitro as I suspect the patient is preload dependent due to right ventricle involvement.
Wayne Smith Wayne Smith Sunday, February 10, 2013 11:22:57 PM Be careful you are starting to sound like one of those ALS types
Doug Harwood Doug Harwood Monday, February 11, 2013 6:16:12 AM Oh yeah..... I forgot the Asa.
William Weq William Weq Thursday, February 14, 2013 4:31:26 PM Complete heart block w/ junction rhythm(in respect to the narrow QRR). Obvious Inferior STEMI. ASA, O2 (SPO2>95%), and NTG with great caution. Consider a higher does of Dopamine, enough to effect rate, and/or pacing to maintain BP with fluids. Pacing is preferred. NTG can be given in Inferior MI with VR-4 elevation; in turn, a greater drop in BP would be expected, also get two large bore IVs on pt. (DON'T WALK THE PT.) http://www.ncbi.nlm.nih.gov/pubmed/2502902
Tom Pattison Tom Pattison Saturday, June 01, 2013 6:36:52 AM CHB, inferior MI probably extending posterior. ST is higher in III than II making RV highly likely. Cath lab should be ready for patient, probable RCA occlusion hitting both SA and AV nodes. Fluid for hypotension, fentanyl for pain.
Ahmad Abdollahi Ahmad Abdollahi Monday, June 24, 2013 4:51:24 PM Kherr ghalbet boovam
Carol N Randy Churchill Carol N Randy Churchill Sunday, January 19, 2014 4:54:18 PM KISS-keep it simple stupid-----back to the basics---- if your sops will let you---then give it
Akbar Bazeghi Akbar Bazeghi Monday, March 10, 2014 1:43:33 PM korah be ali chakerim. to aziz o khosh tipi har jori keh bashie. amrooz rooz khobie bood ham khosrow didam ham hadi. Korahhhhhh vayyyyyyy
Akbar Bazeghi Akbar Bazeghi Monday, March 10, 2014 1:44:05 PM daram degh mokonam a khoshiiiiiiii
Tom Gleeson Tom Gleeson Monday, May 05, 2014 8:57:39 AM This looks like 3rd Degree Heart Block, likely secondary to Inferior STEMI. GTN would be very risky in this patient due to the potential of right ventricular involvement. I would be inclined to continue oxygen, although at a lower flow rate (say 8 LPM) as his Sp02 on room air is sufficient - this is more to potentially treat/acknowledge his symptom of breathlessness. Aspirin would be indicated given this presentation. He is likely short of breath/anxious/diaphoretic due to the bradycardia. Given that he is on antihypertensive medications he is unable to compensate: lisinopril will reduce the efficacy of RAAS and amlodipine reduces vascular smooth muscle contraction (decreasing peripheral vascular resistance) and cardiac muscle contraction (negative inotrope). Combined with 3rd degree AV block (meaning he is unable to increase heart rate to increase cardiac output) this patient is unable to autonomically compensate and may be potentially hypotensive for this patient. Therefore some IV NaCl could be beneficial, although not too much as the possibility of fluid overload and APO is there. Given it is 3rd degree AV block, there is no conduction through the AV node whatsoever; this means atropine is unlikely to work, given that it mainly works in the SA and AV nodes. I would think that transcutaneous cardiac pacing would be beneficial. A catheter lab activation is warranted - ultimately this patient needs revascularisation and potentially a dual chamber pacemaker.
Jeremy Hawk Jeremy Hawk Monday, May 05, 2014 1:48:04 PM I just saw this a few minutes ago... I'd call this a 3rd Degree block with a junctional escape rhythm. This also looks like an IWMI with posterior extension and strong suspicion of RVI as well. Since I have a 12-lead capable machine available, I'm going to check V4R before instituting any pharm interventions that can drop blood pressure. I would say that SL nitro would be contraindicated at this point. While I'd have to give 0.5 mg atropine, I'm not expecting any significant results from it (transient at best), so I'm going to have the pacer ready. I'd probably give judicious fluid boluses, O2, ASA, and transport to a facility that has a PCI lab. He's probably lost a good chunk of his heart as it is, the PCI would be to salvage what's left. I would expect that he's going to need an AV pacer, if he hopefully he survived.
Richard Macaluso Richard Macaluso Tuesday, May 06, 2014 1:42:17 AM Prophylactic ASA, would ditch on nitro as PT is too Brady then if no improvement I would go for an epi push failing that I would go with TCP as there are is a very short st and no p I would go for TCP failing the above suspect SA node suppression as absence of P wave shows little to no pre-fire of the atriums PT seems to stabilize a little with high o2 but the Brady rhythm would be my greatest concern so I would go with TCP hope to hell I get a decent capture and get his BPM up. If successful with TCP I would then put cath lab on standby for temp install of pacemaker if PT improves then I would advise a permanent one. The o2 Sat's are good they just are not going anywhere fast enough so My call still comes full circle to TCP I disagree with Tom if there is a "Total AV node" (unless I missed something 3rd degree does mean total). block he would not have lasted till EMS got there, they're is Sat's in a reasonable way so the ventricles are working they are suppressed in terms of the SA node sending out enough pulses the firing signal comes from the SA node not the AV Node the AV node is nothing but a resistor to keep the Bundle of HIS from getting the signal too early, AV node block would literally hit the off switch long before you could hit lights and sirens. So I am betting on a Pacer for both ventricles due to SA Node failure (*Pending) and possibly both ventricles as well to sync the heart back to normal rhythm and sever the AV Node connection. I would avoid large doses of fluids on the outside chance of tapenade. Again the Brady could suggest tapenade so pushing fluids to throw gas on a match ain't a good call for me. I see no diuretic for the BP so build up of fluid is likely. So TCP to Stabilize, Exam for Tamp, Then failing all else install pacer.
Richard Macaluso Richard Macaluso Tuesday, May 06, 2014 1:45:19 AM PS Shortness of breath does increase my suspicion of Tamp.
Aharon Openheimer Aharon Openheimer Tuesday, May 06, 2014 4:05:52 AM rhythem 3AVB ACG inferior wall STMI I think that he have cardiac cat I teart with IV line try Atropin , and make SB pace continue monitoring
Aharon Openheimer Aharon Openheimer Tuesday, May 06, 2014 4:06:31 AM rhythem 3AVB ACG inferior wall STMI I think that he have cardiac cat I teart withgive Aspirin IV line try Atropin , and make SB pace continue monitoring

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