I am looking for some sage advice and maybe some finger pointin' to where I need to find further information.
I am currently an EMS paramedic who is working on her degree in nursing. However, I cannot find much information in my textbooks (for nursing) about fluid overload and electrolyte imbalances.
In short, one of my EMS calls involved a 60ish year old male patient who presented with an anterior AMI --- symptoms of sudden-onset anterior chest heaviness (10/10 pain) radiating to the left arm that occurred while sitting. (+) nausea, (-) vomiting, (-) SOB, (-) trauma. 15 minute duration. Initial BP of 106/70, HR of 66 (weak/regular radial pulses), R: 24, SpO2 of 97%. GCS of 15. Skin: pale, warm, dry. No difficulty breathing was again confirmed. Lungs clear to all fields. No peripheral edema. No hx of this pain.
Hx: CAD, GERD. recent prostate surgery 2 weeks ago.
Supplemental oxygen was administered on scene, and patient already took a 325 mg aspirin prior to EMS arrival. Initial 12-lead ECG showed hyperacute T waves in the anterior leads, which progressed to ST elevation during rapid transport. 12-lead was transmitted to the ED early enroute. Inferior leads began showing small reciprocal changes on arrival to the ED.
Two 18g IV lines (one with NS and the other a saline lock) were established with a blood draw for the hospital, and one nitroglycerin administered (0.4 mg SL; protocol allows us to administer NTG until the systolic BP falls below 90 mmHg or patient is pain-free).
Patient's BP five minutes after the NTG was 92 mmHg (palpated). I chose to withhold additional NTG due to the borderline BP in conjunction with the patient's reported new-onset of dizziness and generalized weakness. Pain did decrease to a "7". About 300 mL of NS was already infused --- lungs again were clear, no difficulty breathing reported, no edema. I chose to continue the fluids to improve his pressure before considering more NTG --- we were 2 minutes from the hospital at this time.
On ED arrival, the physician ordered another 1000 mL of NS and to withhold the nitro drip until the pressure increased (was just a hair over 100 mmHg systolic when obtained at the ED, if I remember right). The patient received 600 mL of NS by the time I finished verbal report and handed care over to the RN (I TKO'd the infusion once we entered the ED doors). Again, lungs were clear and no reports of difficulty breathing by the patient.
So here's my question: Did I "fluid overload" my AMI patient? What was the risk of shifting his electrolytes significantly with this amount of NS?
I was reprimanded based on several things, but contributing was the fact was that I did not administer a second NTG during transport and that I infused too much fluid to cause concern for fluid overload and electrolyte shifts. My Service Director (EMS "boss") who brought forth these concerns was previously an ICU RN (I apologize for not knowing the specialty) before returning to EMS as our Director.
I still feel confident in how I treated this patient knowing that the ED physician continued the same train of thought in his orders, and that the patient did have a significant occlusion as found by the cath lab. What has bugged me is that I recently learned that now my Service Director has used me as the Village Idiot example outside of our service. While he has not used my name or referenced to my station/shift, it was learned that I was used as an "example" to why some of our future medics required further education, and based it on this particular case. I am not an outspoken person at all, but this really rips at me.
Honestly, if I "did wrong", please let me know. I know the last thing a patient needs with an AMI is more work for the heart. The last thing I would ever want to do is cause more harm to my patients or make the receiving RNs' lives more difficult. If anyone has a literary reference to a textbook or other source that could offer a better understanding of fluid and electrolyte shifts, I would greatly appreciate it! I would like to speak to my Medical Director (physician) about the call as well, but armed with far more knowledge on fluid and electrolyte balance than what I currently have.
