Anferior MI and NO order for NTG drip...

needsmore$ · Dec 29, 2004

do you have staff meetings? we have combined meetings at times w/ the ed physicians and have a "grand rounds" presentation- many times we discuss a difficult case and listen to the options or ideas that others have to provide improved care for the future. we include all that participated in the care of the case being discussed.

by the way- was it an inferior or anterior mi? i have never heard of an anferior mi-unless maybe that's a new term for anterior/inferior combo mi- like anteroseptal??

good luck

anne

veetach · Dec 30, 2004

If this pt had an inferior wall MI I can see why he didnt want a nitro gtt.

On the other hand, The sublinqual nitro is much more potent than IV nitro, just because she went hypotensive with S-L nitro does not mean she cant handle an IV gtt. of Nitro.

rjflyn, ASN, RN · Dec 31, 2004

On another note if the inital nitro didnt help the pain the IV nitro may not either. I have had doctors hold it for just this reason. It is also at times used for blood pressure control but you stated the pts systolic BP was 110-130 so probably no need for it for this reason either. Most often times it was doctors who have been around a while who have done this. Newer ER docs seem to be more aggressive and will try it regaurdless. Also like above some types of MI you dont give nitro.

just a thought.

rj

UCDSICURN · Dec 31, 2004

From my experience, if Nitro is not effective this indicates a couple of things. The lesion/blockage, for this particular type of MI is high up on the LCA or the LAD and cardiac tissue is still being damaged. The relief came with stent placement, nothing else. One particular gentleman was in his 40's, was TNK'd in the ER and reinfarcted in our CCU. High dose Nitro 130mcg's+ and loads of morphine did nothing for him. Four stents did however.

The others are correct about an inferior wall MI with right sided heart failure, nitro is a no no, as is anything that will vasodilate the vasculature.

D.C.

LPN47331 · Jan 3, 2005

Just recieved news yesterday that the pt on arrival went into v-tach.

Coded her and found out she had 100% blockage of her RAC. They placed 2 stents and she is now doing fine.

LPN47331 · Jan 3, 2005

do you have staff meetings? we have combined meetings at times w/ the ed physicians and have a "grand rounds" presentation- many times we discuss a difficult case and listen to the options or ideas that others have to provide improved care for the future. we include all that participated in the care of the case being discussed.
by the way- was it an inferior or anterior mi? i have never heard of an anferior mi-unless maybe that's a new term for anterior/inferior combo mi- like anteroseptal??
good luck
anne

it was an anterior.....

mattsmom81 · Jan 3, 2005

???100% blockage of her RCA and it was an anterior MI????? I agree Nitro should not be a kneejerk reaction for all MI's...gotta look at the type of MI, the fluid volume status of the patient, vital signs. Sometimes the best firstline treatment for AMI is right to cath lab and PTCA/ stent. :)

plato353 · Jan 3, 2005

presumably you meant the patient had an anterior mi due to the nitro tx.however i do think that this patient would have benefitted from from a complete assessment prior to the presciption of 4mg of mg sulfate.ekg or ecg here in britain is normally done following a vital sign assessment. :coollook:

its not good to play russian roullette with the elderley blood pressure you are asking for trouble.i presume that is the sequence that the physian has operated on.well it could be that your physician is new as mentioned but one does not prescribe and then and then obtain definitive investigations.

i hope this helps as you always have to be careful and weary of physicians who practice like this.the fact that you have casted doubt shows you awareness and can only benefit the pateint:)

candyndel · Jan 7, 2005

oops

You meant inferior (anferior? ), correct? (RCA=inferior) Pts that infarct their inferior wall are more likely to expierence the hypotension caused by NTG, as well as be bradycardic. They almost always cant get an IV beta-blocker, another standard of MI care. Are you using 300mg Plavix, also?

Agreed, hypotension is more profound with SL than IV. When her pressure came back up >100 (obviously it was transient drop) she should have been started back on IV NTG, albeit slowly,as tolerated. Was she symptomatic with that low BP? What about Zofran SL???

Older pts are lucky and have more collateral circulation. If she was a 40 yo male, she probably wouldnt have made it!!

Every MI (not counting vasospastic MIs...) should go straight to the cath lab! If unavailable, lytics and transfer to Stent City!!! i tell my family what hospital to go to should they have chest pain-one with a fully functioning CCL!

PA-C in Texas · Jan 8, 2005

I am really confused after reading this thread.

It sounds to me like there might be significant involvement of the right ventricular wall. I am a big advocate of getting right-sided leads in ALL inferior MI's, but I know that this is frequently not done.

The NTG in this case is a discretionary call. I happen not to agree with it, but I can understand the rationale for being very cautious in these pre-load dependent patients. Let's not forget that NTG is indicated for the relief of ischemic chest pain. It didn't do the job in SL form, and I can understand the reluctance to use it again after such a precipitous drop in BP when it did nothing for the woman's pain. The decision to administer thrombolytics is also a discretionary call that needs to take into account various factors. If PCI is available at the hospital down the street intervention can be performed expeditiously, I would definitely hold off on the thrombolytics.

As someone who makes up words like "anferior", it might not be a good idea to suggest anything to this physician.

wv_nurse 2003 · Jan 8, 2005

I am really confused after reading this thread.
It sounds to me like there might be significant involvement of the right ventricular wall. I am a big advocate of getting right-sided leads in ALL inferior MI's, but I know that this is frequently not done.
The NTG in this case is a discretionary call. I happen not to agree with it, but I can understand the rationale for being very cautious in these pre-load dependent patients. Let's not forget that NTG is indicated for the relief of ischemic chest pain. It didn't do the job in SL form, and I can understand the reluctance to use it again after such a precipitous drop in BP when it did nothing for the woman's pain. The decision to administer thrombolytics is also a discretionary call that needs to take into account various factors. If PCI is available at the hospital down the street intervention can be performed expeditiously, I would definitely hold off on the thrombolytics.
As someone who makes up words like "anferior", it might not be a good idea to suggest anything to this physician.

EXCELLANT post!! I do question the posted diagnosis of anterior MI with an RCA blockage :confused: I have seen right ventricular MI's bottom out with NTG--going into shock. A right sided EKG could have answered the question of whether or not this was a right ventricular infarct.