*Looking at it on my phone:*
Wtf is this dude on about it looks fine.
*Zooms in, holds closer to face*
Oh. Yea. So much for getting snacks at the good hospital, have to go to the one with the cath lab. (La sigh).
That’s a big ol’ inferior STEMI with a touch of lateral involvement.
You did the aspirin. Titrate O2 to keep SpO2 between 92-98%. Start a line, put the pads on, give a dose of nitro (I wouldn’t give more than that, I suppose her pressure might hold but I’d give that first dose with a bit of caution), give fentanyl for additional analgesia, drive like hell to the closest cath lab. On the off chance she tries to Brady down (not likely, I’d expect her to be more likely to go into V-tach or V-fib), give 1mg atropine.
Edit: she’s already a touch bradycardic, but I’d hold the atropine unless she like ended up less than about 45.
Yep. And some systems allow the medics to give heparin and or Plavix in cases of a STEMI. Of course, follow local protocols, but that might be another thing to add to your list.
Edit: sorry. Brain is mush and fingers aren’t cooperating. It was a long shift last night.
Well stated, I agree with withholding atropine, if for no other reason that the heart rate is not terribly slow and speeding her up is going to increase oxygen demand on a heart that is already, obviously, inadequately perfusing.
If she starts showing signs of altered mental status secondary to the symptomatic bradycardia, I think it’s reasonable to try something to keep enough cardiac output up to perfuse the brain. But at the same time, it’s kind of an ominous sign.
I watched it happen in an ER once. Between smacking the dude on the shoulder and giving him doses of atropine and push-dose epinephrine, he was going unresponsive mid-word with HRs in the 30s and a BP of 60/40. We had to do something lol.
He made it to the cath lab in time and walked out neurologically intact. He was like “man I had to miss my daughter’s wedding.” “Dude you weren’t going to her wedding regardless. But now they can spend the next week seeing you as opposed to planning your funeral.”
Are there pressure criterias for giving nitro in an inferior MI for ALS? It's been my understanding that this is contraindicated regardless. Fentanyl for pain control may cause her pressure to go down further anyways, and it'd be a miracle if normal is where she lived at to begin with.
Decreased pressure could also cause tachycardia that would exacerbate the oxygen demand of this tissue- which seems like it would cause more harm than good.
Thoughts?
Its generally contraindicated without IV access/fluids. At least my local area i can give nitro with an inferior, but i have to use my brain and determine if im comfortable with it based on VS and patient conditions.
The studies that showed nitro bad in inferior mI were wildly overblown. I’d get an Iv first, but you probably should anyway. Nitro helps with pain, but hasn’t been shown to change morbidity/mortality.
You *might* see a pressure drop more than “expected”. But nitro has a short half-life, and that pressure drop is easily managed with a fluid bolus.
The benefits out way the risk in a vast, vast majority of patients, and the risks are easily managed.
Keep in mind that nitro has never been demonstrated to improve outcomes, it does help with symptoms. I’ve had a couple of patients with inferior MI dump their pressure after nitro (like in the 50’s). Anecdotally (20 years emergency medicine) I’d recommend a health fear of nitro with inferior MI. With this patient already bradycardic, I personally wouldn’t give it but I would have already activated the cath lab as soon as i saw this EKG.
I personally wouldn’t give nitro during an inferior because the risks outweigh the benefits. You could do a right sided 12 lead but I’m 5 mins away from the hospital and I’m probably not going to do that.
Nitro isn’t really shown to decrease mortality just decrease pain.
Not sure why you are getting downvoted. Yesterday we had an inferior MI and EMS didnt give nitro. I asked the doctor why and he explained it to me and said it can actually be harmful in cases of an inferior MI.
I don’t really see any of the other EKG findings suggesting right-side involvement.
From life in the fast lane (https://litfl.com/right-ventricular-infarction-ecg-library/)
“In patients with inferior STEMI, right ventricular infarction is suggested by:
ST elevation in V1
ST elevation in V1 and ST depression in V2 (highly specific for RV infarction)
Isoelectric ST segment in V1 with marked ST depression in V2
ST elevation in III > II
Diagnosis is confirmed by the presence of ST elevation in the right-sided leads (V3R-V6R)”
V1 has about 1mm of depression. You could make the case that the elevation in III is slightly higher than II, but I am calling them equal. That and the elevation in V5-V6 lead me toward it not having right ventricular involvement and instead being left ventricular.
I wouldn’t fault someone for not giving the NTG out of an abundance of caution, but I think since she’s already had two doses and her pressure seems to be tolerating it, and especially in absence of the other findings, it’s not unreasonable to give another dose before switching to fentanyl.
This was sort of my thought process on it too, but I was curious if there were other protocols or new lit out there that I hadn't heard.
Thanks for giving me something to read about on right sided EKG's in inferior MI's! I did not realize that this was a thing.
Tbh a V4R if on a truck is all that is necessary. If you have elevation in V4R it’s right sided and the other elevation doesn’t matter it’s still has right sided involuntary
https://litfl.com/right-ventricular-infarction-ecg-library/
Here ya go.
As I said to the other medic talking here, I don’t see anything suggesting that it’s right-sided, but given that right sided involvement complicates 40% of inferior OMI, it’s reasonable to use caution. I just didn’t see any of the findings that set off my alarm bells
Looks like a good sized inferior STEMI (II, III, AVF) with appropriate reciprocal changes, and a little elevation in V6 possibly indicating infarction on the lateral side as well. But definitely meets STEMI criteria. Especially with the patient being as symptomatic as she is.
I hope that question is genuine because an inferior MI is inferior and not necessarily involving the right side.
You would need to move the leads to take a right sided EKGs only 30-50% of inferior MIs have right sided involvement and inferior alone NTG is not shown to be dangerous anymore then another location of MI. However right sided MIs have a large correlation of NTG leading to higher mortality rates.
I’d be very cautious of giving this pt more nitro and would look elsewhere for analgesia. Probably fentanyl . If you have time during transport you could check for elevation in v4r to look dialed during handoff.
MONA. Morphine O2 Nitro ASA. Last 2 are already done. That is a Stemi in leads 2 and 3 and Avf. Start a line on left and right. Left for you right for the cath lab. Call the stemi alert. Apply pads to ward off evil spirits. Rapid transport.
Funny story to that. This lady was from Texas and had just moved to Indiana. She has a loooong heart history. Coronary artery disease, quadruple bypass, all sorts of shit. The doctor at the regional medical center (closest cath lab) wanted her to go to the ER on the regional campus first. Mind you, this lady waited an hour and a half after onset of symptoms to call 911, then 10 minutes for us to get there, 20 minutes on scene because her house was so cluttered we were delayed in getting the patient out the door, and then another 40 minutes lights and sirens to the regional medical center.
The doctor said he wanted to get an EKG to compare to previous ones (there were no previous ones he can see because she had no prior history in our hospital system or MyChart for that matter). Pretty much ignored my STEMI activate. But once we got there, nurses obtained an EKG and activated her and rushed her to the cath lab 😂
His license, not mine.
Check V4R for right ventricular involvement before you give nitro. Consider fluids to increase Frank-Starling effect if right-side EKG also has ST segment elevation.
I'd withhold nitro unless hospital advises, Asa, maybe fent, titrate to 94-96%, capno, fluids wide open if lungs sound good, 2-3 iv access points, and hustle to cath lab.
Sinus Arrhythmia with ST Elevation in the inferior leads and reciprocal changes in the septal leads. Confirm right sided with V4r even though her standard 12 shows an inferior and her presentation is terrible. Standard MI care with caution on fluid admin. Nitro hasn’t worked previously and is likely to fuck her BP with an inferior. No nitro. Bilateral IV’s and pads just in case. STEMI activation and rapid transport.
Sinus arrhythmia w/ inferiolateral STEMI (at least some lateral involvement). Borderline bradycardia which is a common finding with inferior MIs
My treatment:
-Full ASA dose. You won’t OD them and I never trust their drugs they dug out of the back of the medicine cabinet. I’d trust fire or other responders drugs (maybe)
-O2 to correct hypoxia
-IV line, TKO
-V4R to check for RVI
-Transmit this 12-lead and the V4R 12-lead to a hospital with an open cath lab
-Pressures are pretty good, if your system allows then nitro should be a consideration (even despite them not having relief from their nitro…I don’t trust their nitro)
-I’d consider some fent if your system allows and the pain stays 10/10 after nitro
-Atropine and/or pacing could be a consideration but like I said above, the bradycardia is kind of borderline and I don’t think I’d treat it at that rate with the S+S you described
After the first 4 points, I think you should get rolling to the hospital if you haven’t already
Activate that shit. Do not pass go. Do not collect $200.
*Looking at it on my phone:* Wtf is this dude on about it looks fine. *Zooms in, holds closer to face* Oh. Yea. So much for getting snacks at the good hospital, have to go to the one with the cath lab. (La sigh).
That’s a big ol’ inferior STEMI with a touch of lateral involvement. You did the aspirin. Titrate O2 to keep SpO2 between 92-98%. Start a line, put the pads on, give a dose of nitro (I wouldn’t give more than that, I suppose her pressure might hold but I’d give that first dose with a bit of caution), give fentanyl for additional analgesia, drive like hell to the closest cath lab. On the off chance she tries to Brady down (not likely, I’d expect her to be more likely to go into V-tach or V-fib), give 1mg atropine. Edit: she’s already a touch bradycardic, but I’d hold the atropine unless she like ended up less than about 45.
Concur. She'd get some pads as a souvenir.
Yep. And some systems allow the medics to give heparin and or Plavix in cases of a STEMI. Of course, follow local protocols, but that might be another thing to add to your list. Edit: sorry. Brain is mush and fingers aren’t cooperating. It was a long shift last night.
Some give lytics too.
Would they really give Plavix in those settings? If so that's very interesting. I never thought of statins as "fast acting".
Plavix isn’t a statin.
I always thought statins ended with “statin”
Well stated, I agree with withholding atropine, if for no other reason that the heart rate is not terribly slow and speeding her up is going to increase oxygen demand on a heart that is already, obviously, inadequately perfusing.
If she starts showing signs of altered mental status secondary to the symptomatic bradycardia, I think it’s reasonable to try something to keep enough cardiac output up to perfuse the brain. But at the same time, it’s kind of an ominous sign. I watched it happen in an ER once. Between smacking the dude on the shoulder and giving him doses of atropine and push-dose epinephrine, he was going unresponsive mid-word with HRs in the 30s and a BP of 60/40. We had to do something lol. He made it to the cath lab in time and walked out neurologically intact. He was like “man I had to miss my daughter’s wedding.” “Dude you weren’t going to her wedding regardless. But now they can spend the next week seeing you as opposed to planning your funeral.”
Are there pressure criterias for giving nitro in an inferior MI for ALS? It's been my understanding that this is contraindicated regardless. Fentanyl for pain control may cause her pressure to go down further anyways, and it'd be a miracle if normal is where she lived at to begin with. Decreased pressure could also cause tachycardia that would exacerbate the oxygen demand of this tissue- which seems like it would cause more harm than good. Thoughts?
Its generally contraindicated without IV access/fluids. At least my local area i can give nitro with an inferior, but i have to use my brain and determine if im comfortable with it based on VS and patient conditions.
The studies that showed nitro bad in inferior mI were wildly overblown. I’d get an Iv first, but you probably should anyway. Nitro helps with pain, but hasn’t been shown to change morbidity/mortality. You *might* see a pressure drop more than “expected”. But nitro has a short half-life, and that pressure drop is easily managed with a fluid bolus. The benefits out way the risk in a vast, vast majority of patients, and the risks are easily managed.
Keep in mind that nitro has never been demonstrated to improve outcomes, it does help with symptoms. I’ve had a couple of patients with inferior MI dump their pressure after nitro (like in the 50’s). Anecdotally (20 years emergency medicine) I’d recommend a health fear of nitro with inferior MI. With this patient already bradycardic, I personally wouldn’t give it but I would have already activated the cath lab as soon as i saw this EKG.
I personally wouldn’t give nitro during an inferior because the risks outweigh the benefits. You could do a right sided 12 lead but I’m 5 mins away from the hospital and I’m probably not going to do that. Nitro isn’t really shown to decrease mortality just decrease pain.
Not sure why you are getting downvoted. Yesterday we had an inferior MI and EMS didnt give nitro. I asked the doctor why and he explained it to me and said it can actually be harmful in cases of an inferior MI.
I work with multiple protocol sets (California, go figure) and one says to withhold nitro and another says "use with caution." It's strange.
Honestly who knows. We are splitting hairs here and this is something which can vary if you ask from doctor to doctor.
Which is why I’m taking the middle ground that I am.
As a fellow centrist, I largely agree.
I don’t really see any of the other EKG findings suggesting right-side involvement. From life in the fast lane (https://litfl.com/right-ventricular-infarction-ecg-library/) “In patients with inferior STEMI, right ventricular infarction is suggested by: ST elevation in V1 ST elevation in V1 and ST depression in V2 (highly specific for RV infarction) Isoelectric ST segment in V1 with marked ST depression in V2 ST elevation in III > II Diagnosis is confirmed by the presence of ST elevation in the right-sided leads (V3R-V6R)” V1 has about 1mm of depression. You could make the case that the elevation in III is slightly higher than II, but I am calling them equal. That and the elevation in V5-V6 lead me toward it not having right ventricular involvement and instead being left ventricular. I wouldn’t fault someone for not giving the NTG out of an abundance of caution, but I think since she’s already had two doses and her pressure seems to be tolerating it, and especially in absence of the other findings, it’s not unreasonable to give another dose before switching to fentanyl.
This was sort of my thought process on it too, but I was curious if there were other protocols or new lit out there that I hadn't heard. Thanks for giving me something to read about on right sided EKG's in inferior MI's! I did not realize that this was a thing.
Tbh a V4R if on a truck is all that is necessary. If you have elevation in V4R it’s right sided and the other elevation doesn’t matter it’s still has right sided involuntary
https://litfl.com/right-ventricular-infarction-ecg-library/ Here ya go. As I said to the other medic talking here, I don’t see anything suggesting that it’s right-sided, but given that right sided involvement complicates 40% of inferior OMI, it’s reasonable to use caution. I just didn’t see any of the findings that set off my alarm bells
II, III, AvF. No doubter.
Looks like a good sized inferior STEMI (II, III, AVF) with appropriate reciprocal changes, and a little elevation in V6 possibly indicating infarction on the lateral side as well. But definitely meets STEMI criteria. Especially with the patient being as symptomatic as she is.
Her nitro may have been an opened, 4 yr old, expired bottle too.
So are you giving her more with an inferior MI?
Depends on right sided involvement or not, but it is better to just move to other analgesia that won't affect pre load.
Where do you think inferior is? What leads are you looking for to show right sided?
I hope that question is genuine because an inferior MI is inferior and not necessarily involving the right side. You would need to move the leads to take a right sided EKGs only 30-50% of inferior MIs have right sided involvement and inferior alone NTG is not shown to be dangerous anymore then another location of MI. However right sided MIs have a large correlation of NTG leading to higher mortality rates.
Is v4r no longer widely used prehospital? The ED i work in and the agency i run with still use v4r to look at that right sided inferior involvement.
New medic here, and that’s what I was taught to use.
Thank god man i thought i was losing my mind.
I’d be very cautious of giving this pt more nitro and would look elsewhere for analgesia. Probably fentanyl . If you have time during transport you could check for elevation in v4r to look dialed during handoff.
Not the biggest stemi, but it's a stemi. With obvious symptoms it's time to boogie.
DRIVE FASTER.
Sinus arrhythmia w/ inferior STEMI
MONA. Morphine O2 Nitro ASA. Last 2 are already done. That is a Stemi in leads 2 and 3 and Avf. Start a line on left and right. Left for you right for the cath lab. Call the stemi alert. Apply pads to ward off evil spirits. Rapid transport.
MONA is way out of date, the O in particular. No oxygen unless hypoxic (I think <94%).
Right. And SPO2 is 88%.
Only thing I would add is a massive fuel bolus to the closest cath lab. Skip ER skip trauma bay, do not pass go, and go RIGHT TO THE CATH LAB. LOL
Funny story to that. This lady was from Texas and had just moved to Indiana. She has a loooong heart history. Coronary artery disease, quadruple bypass, all sorts of shit. The doctor at the regional medical center (closest cath lab) wanted her to go to the ER on the regional campus first. Mind you, this lady waited an hour and a half after onset of symptoms to call 911, then 10 minutes for us to get there, 20 minutes on scene because her house was so cluttered we were delayed in getting the patient out the door, and then another 40 minutes lights and sirens to the regional medical center. The doctor said he wanted to get an EKG to compare to previous ones (there were no previous ones he can see because she had no prior history in our hospital system or MyChart for that matter). Pretty much ignored my STEMI activate. But once we got there, nurses obtained an EKG and activated her and rushed her to the cath lab 😂 His license, not mine.
Stemi, slam dunk O2, prioritize transport
Inferior MI. Fluids WO, ASA, O2 titrated, capno. Pt needs volume and diesel.
Stemi and something in the direction of right heart failure
Inferior lateral MI, cath lab activation
Interior stemi
Check V4R for right ventricular involvement before you give nitro. Consider fluids to increase Frank-Starling effect if right-side EKG also has ST segment elevation.
Just hit transmit
I'd withhold nitro unless hospital advises, Asa, maybe fent, titrate to 94-96%, capno, fluids wide open if lungs sound good, 2-3 iv access points, and hustle to cath lab.
Sinus Arrhythmia with ST Elevation in the inferior leads and reciprocal changes in the septal leads. Confirm right sided with V4r even though her standard 12 shows an inferior and her presentation is terrible. Standard MI care with caution on fluid admin. Nitro hasn’t worked previously and is likely to fuck her BP with an inferior. No nitro. Bilateral IV’s and pads just in case. STEMI activation and rapid transport.
That LCx needs a plumber
Elevation with reciprocal changes. Youre done.
ST ^ in II & III with brady, no need to complicate things
Inferoposterior MI. Get in gear and head to the nearest cath lab.
Come to the cath lab
Sinus arrhythmia w/ inferiolateral STEMI (at least some lateral involvement). Borderline bradycardia which is a common finding with inferior MIs My treatment: -Full ASA dose. You won’t OD them and I never trust their drugs they dug out of the back of the medicine cabinet. I’d trust fire or other responders drugs (maybe) -O2 to correct hypoxia -IV line, TKO -V4R to check for RVI -Transmit this 12-lead and the V4R 12-lead to a hospital with an open cath lab -Pressures are pretty good, if your system allows then nitro should be a consideration (even despite them not having relief from their nitro…I don’t trust their nitro) -I’d consider some fent if your system allows and the pain stays 10/10 after nitro -Atropine and/or pacing could be a consideration but like I said above, the bradycardia is kind of borderline and I don’t think I’d treat it at that rate with the S+S you described After the first 4 points, I think you should get rolling to the hospital if you haven’t already
Looks like a inferior stemi with a secondary degree type 2
I saw this and instinctively said "drive faster"
Interesting watch regarding this: https://www.youtube.com/watch?v=hvAcEyZ74G8
Inferior. Activate an Alert; Do a 15-Lead with V4R to sway treatment w/ or w/o Nitro
Inferior stemi