"I feel like crap"

[wvditchdoc]

That was the Chief Complaint of this guy that walked into our clinic one day here in the Big Sandbox. Take a look, tell me what you think, and I will post more later.

55 y/o male
CP, SOB, sweating like a pig.
Hypotensive.
Pulse of 40-45 weak but regular.
Pain for greater than one day.

[mediccjh]

Holy ****, that's not good.

At least an inferior wall MI.

Hi-flow O2, ASA, 2 IVs (1 wide), maybe even pace.

[GaHazMedic]

I agree that it is an MI. However, I disagree with running an IV WO. This patient has significant myocardial injury. You do not want to pump in a bunch of fluid. This increases the preload, which you don't want to do. As symptomatic as he is you should go straight to TCP. If that doesn't raise his pressure (or you cannot get capture, which is likely with this much damage), then hang dopamine or whatever vasopressor you have. Use WO fluids only as a last resort if all else fails. The patient does need 2 lines. One KVO and one for the vasopressor to piggyback into. ASA and O2 is a given. Be prepared to work a code on this one.

[mediccjh]

I'm going to disagree and here's why.

Inferior wall MIs are indicative of right-side MIs. The papers say to treat these with fluid. Using dopamine will increase myocardial oxygen demand, and the heart is stressed enough as it is.

[wvditchdoc]

Dopamine does increase the Inotropic properties of the heart, more so than the Chronotropic qualities. Course if you don't do anything they are going to be DRT anyway. A lot of times fluid alone won't do the trick. The lesser of 2 evils comes to mind. Dopamine is the better choice for this reason, Dobutamine is by far a worse choice for Ischemia.

Inferior it is. Same patient a short time later, now name that rhythm......

[fishy]

Notice the T waves in V1 and V2 in the first strip and in aVF (to lesser extend) in the second one. I don't now what they're called in english, but we have a special term for them (lit. "suffocating Ts"). This one is fresh and coming in strong. I've personnally never seen 'those' T waves, only in textbooks.

Edit: medical dictionary says: "anoxic T(-waves)"

[scotttt]

STE in II, III, avF, V1&V2, and reciprical changes in lateral limb leads make this a slam-dunk for STEMI. Also, RBBB (V1 is obscured bythe STE, but the classic RBBB pattern is in V6)and possible 3rd degree AVB (would prefer a longer strip to better evaluate p waves).

Was a right sided ECG performed? I imagine this is extended into his RV. If he is hypotensive, I'd have no issue with starting fluids as long as he has no outward signs of pulmonary edema. Part of his hypotension may very well be due to the fact that his RV can't generate a decent preload. ASA, two large-bore lines preferably. If no improvement with fluid, sedation and pacing depending on BP and mentation. I'd stay away from pressors if possible (no doubt they may be needed). Pacing or not, he gets the pads placed anyways ("sir, these big pads help to better monitor you heart").

And also, he gets the express to a PCI hospital.

What was his BP, anyhow?

[wvditchdoc]

And also, he gets the express to a PCI hospital.

What was his BP, anyhow?

No PCI hospital in Northern Iraq, sorry.

Initial BP was 70/nothin

Initial 25 min Air MEDEVAC to Local Combat Support Hospital where he crashed twice after getting Dope, TNK, and Heparin. Paced and then hauled *** on a great big cargo jet to a nice little Hospital in Germany. Where he subsequently had 5 stents placed by the USA's finest.

Made it back to the States walking, talking and alive. That is all that matters.

[mike]

Wide or narrow complex Mr. ONE stitch?

[screaming pizza]

No PCI hospital in Northern Iraq, sorry.

Initial BP was 70/nothin

Initial 25 min Air MEDEVAC to Local Combat Support Hospital where he crashed twice after getting Dope, TNK, and Heparin. Paced and then hauled *** on a great big cargo jet to a nice little Hospital in Germany. Where he subsequently had 5 stents placed by the USA's finest.

Made it back to the States walking, talking and alive. That is all that matters.

Where'd you stabilize him, QWest? Decent place, but good for you, what with the nasty-*** weather up there around this time of the year.

[mike]

Where'd you stabilize him, QWest? Decent place, but good for you, what with the nasty-*** weather up there around this time of the year.

North but not east. Thats the easiest way to say it without saying it:)

[AMRemt]

I'll go with.... SH*T call the medics

[fm_emt]

No PCI hospital in Northern Iraq, sorry.

Initial BP was 70/nothin

Initial 25 min Air MEDEVAC to Local Combat Support Hospital where he crashed twice after getting Dope, TNK, and Heparin. Paced and then hauled *** on a great big cargo jet to a nice little Hospital in Germany. Where he subsequently had 5 stents placed by the USA's finest.

Made it back to the States walking, talking and alive. That is all that matters.

Any idea how the guy is doing now? The strips have a date in Oct 05 on them.

[wvditchdoc]

He is doing fine, back to work appparently.

[NomexMedic]

STE in II, III, avF, V1&V2, and reciprical changes in lateral limb leads make this a slam-dunk for STEMI. Also, RBBB (V1 is obscured bythe STE, but the classic RBBB pattern is in V6)and possible 3rd degree AVB (would prefer a longer strip to better evaluate p waves).

Not to call you out, I'm saying this because I'm unsure. I was taught that a bundle branch block makes you unable to diagnose an MI. Also, in the first 12-leads his QRS is 0.84. Where are you seeing the RBBB? What is the terminology I'm looking for in the above statement about not being able to diagnose an MI with a BBB?

[Medic101Charlie]

Not to call you out, I'm saying this because I'm unsure. I was taught that a bundle branch block makes you unable to diagnose an MI. Also, in the first 12-leads his QRS is 0.84. Where are you seeing the RBBB? What is the terminology I'm looking for in the above statement about not being able to diagnose an MI with a BBB?

"Extreme concordance" or "extreme discordance" is how you diagnose MI in a BBB.

Instead of looking for traditional ST elevation of t-wave inversion, you look for either extreme concordance (same deflection as the last segment), or extreme discordance (opposite deflection as the last segment). 10mm is considered extreme. I'll look for some ECGs from my critical care class and post them.

It is more difficult in left than right but it is possible.

Also, there may be an r-primed in V1 which would be indicative of an incomplete RBBB. It wouldn't be complete because the QRS is not wide and well and there is no deep terminal S-wave in V5-V6.

The deep S in V5 could be due to late repolarization. If it is late enough into the infarct, the heart could be remodeling (the reason why docs give ACE-inhibitors with the first 24 hours of an MI).

My thoughts anyway.

Good should though. inferior wall MI and hypotension with clear lung sounds is the hall mark of right sided infarct. Because they are pre-load dependent, fluid boluses are life saving.

Jim