We have a new ER doc who is very respected as a Family Physician for which this is all he has done for many, many years. We had a 74 yo F with c/o bilat arm pain and burning between shoulder blades. BP was 180/110, rest of vs wnl. Doc ordered NTG SLx3 and pt had no relief. 4mg MSO4 IV given and BP dropped to 59/40. BP came back up even though Doc ordered NS@100/hr.
Pt still had chest pain & rated 9/10. EKG showed anferior MI, ck-mb 64, Trop I = 9.6. I asked the Doc if he wanted to start a NTG drip. He said no due to previous drop in BP. Pt then c/o nausea and I asked for some phenergan, zofran, etc. Doc said no....because of BP, which she was SBP 110-130. This pt was extremely symptomatic and we did nothing for. She was transferred to a cardiac facility and had 2 stents placed that night.
I discussed this with the ER director and he stated a NTG drip was the appropriate treatment regardless of episode of low BP. I felt completely useless for this pt. I have been working ER for 4 yrs and am an LPN. I just did not know how to respond to this situation. I asked my ER director if it would be appropriate to make suggestions to this Doc because he is not an ER MD. He said yes it would. I've witnessed some odd situations but this takes the cake. If anybody has any comments or suggestions, I would really like to hear from you. Thanks!
Good post-- we do many rt sided ECGs as well to differentiate-doesn't take long-just switch the V leads around when you finish the initial 12 lead- then you have more info right off the bat!
Why would you be so mean? Perhaps it was a spelling mistake. Even if it wasnt, there is no reason to belittle him/her with that comment.
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.
Older persons do not have collateral circulation unless they have been very active with a exercise program.This is formed over time by having an exercise regimine. They do not form with age.
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!
Actually, collaterals are present at birth but not yet functioning. They are stimulated and develop gradually by either coronary artery disease, myocardial hypoxia or myocardial hypertrophy (AACN, p. 324). The slow development of these vessels supports the myocardium from a gradual and not sudden obstruction. This is why older persons who have had disease developing gradually can have a 100% occlusion (in sometimes >1 artery), yet a normal ECG. This is very common in the elderly population, which is why elective PTCA is so popular. It would be nice to think that all these pts were on a regimented exercise program which prevented them from having an AMI, yet we know this is America, and not the case. When I said more collaterals, I meant more 'developed' collaterals, which is current cardiology nomenclature we all use. Thanks.
Older persons do not have collateral circulation unless they have been very active with a exercise program.This is formed over time by having an exercise regimine. They do not form with age.
Transient hypotension w/NTG...nausea...chest pain...all have the soundings of an inferior wall MI...Right sided EKG...IVF...Cath lab/thrombolytics....I would have held the NTG too...
We have a new ER doc who is very respected as a Family Physician for which this is all he has done for many, many years. We had a 74 yo F with c/o bilat arm pain and burning between shoulder blades. BP was 180/110, rest of vs wnl. Doc ordered NTG SLx3 and pt had no relief. 4mg MSO4 IV given and BP dropped to 59/40. BP came back up even though Doc ordered NS@100/hr.
Pt still had chest pain & rated 9/10. EKG showed anferior MI, ck-mb 64, Trop I = 9.6. I asked the Doc if he wanted to start a NTG drip. He said no due to previous drop in BP. Pt then c/o nausea and I asked for some phenergan, zofran, etc. Doc said no....because of BP, which she was SBP 110-130. This pt was extremely symptomatic and we did nothing for. She was transferred to a cardiac facility and had 2 stents placed that night.
I discussed this with the ER director and he stated a NTG drip was the appropriate treatment regardless of episode of low BP. I felt completely useless for this pt. I have been working ER for 4 yrs and am an LPN. I just did not know how to respond to this situation. I asked my ER director if it would be appropriate to make suggestions to this Doc because he is not an ER MD. He said yes it would. I've witnessed some odd situations but this takes the cake. If anybody has any comments or suggestions, I would really like to hear from you. Thanks!
Its appropiate to make suggestions to an ER MD anytime you feel it appropiate or you have have questions. Of course with me they know better than to not listen to what I say
And then you have an ER doc who, after reading the black box warning on Phenergan, orders it anyway for a 2 month old. Or prescribes Deconamine for an 8 year old. Or has a patient with MI written all over her, with supporting EKG and labs, want to put her in our unit and be seen by a surgeon for a bad gall bladder!!!!
I'll take the doc who is reluctant to use nitro gtt any day!
As someone who makes up words like "anferior", it might not be a good idea to suggest anything to this physician.
That was just plain mean and disrespectful. Ever heard of a typo? Maybe we should search all your posts and see if you've always spelled everything correctly?
What has happened to professional respect? It's mean comments like this from fellow medical professionals that are pushing people out of the field.
That was just plain mean and disrespectful. Ever heard of a typo? Maybe we should search all your posts and see if you've always spelled everything correctly?
What has happened to professional respect? It's mean comments like this from fellow medical professionals that are pushing people out of the field.
Grow up.
Also that is coming from another Texan, and we all know how well our most famous and endearing Texan, aka GWB, or the little bush, or the little shrub or the little.......... We all know he never makes any mistakes whether writing or speecifying
needsmore$
237 Posts
Good post-- we do many rt sided ECGs as well to differentiate-doesn't take long-just switch the V leads around when you finish the initial 12 lead- then you have more info right off the bat!
Anne