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Crushing nitro on right side STEMI!

Posted

Has 2 years experience.

Hi all, I am a nursing student and I work as a tech. Recently while working in the ER we had a walk in with chest pain. We ended up giving nitro and his bp dumped from 140/80 to 60/35....needles to say that was a shocker for me. We ended up transporting the pt to a hospital with a cath lab and he had 95% blockage of his Right coronary. My question is; has anyone else experienced this phenomena and if so what is they best way to handle it? Thank you

~Mi Vida Loca~RN, ASN, RN

Specializes in Emergency Dept. Trauma. Pediatrics. Has 6 years experience.

That's one of the side effects of what can happen with Nitro and RVI, but you don't always know it's right sided before giving the Nitro. This is why you never give nitro to a chest pain person without a line in place. You give them lots of fluid. 2-3 liters if need be and sometimes they can even start Dopamine if it's going to be a long time until they can get the patient to cath lab. That's been my experience.

You're also going to consider Fentanyl for pain in this case and not Morphine.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

This is why the usual rule at every ED I've worked in is to get a 12 lead first, then treat.

~Mi Vida Loca~RN, ASN, RN

Specializes in Emergency Dept. Trauma. Pediatrics. Has 6 years experience.

This is why the usual rule at every ED I've worked in is to get a 12 lead first, then treat.

The problem is they can sometimes be easily missed. Especially to someone newer to reading EKG's, that's when I have usually seen it happen. Not from not getting an EKG first.

Here's why NTG is not a good idea when the RV is ischemic from RCA occlusion. Perfusion from the aortic root down the RCA occurs over systole and diastole (unlike the left main where it is only diastole). The NTG increases venous capacitance, holding blood in reserve in the venous system with the ultimate effect being that less blood returns to the RV for processing through the lungs and being delivered to the LV.

This means that LV stroke volume, cardiac output, and S/D blood pressure falls. This causes a fall in aortic root pressure which causes RCA flow to fall to an already ischemic RV...

Now, not only is less blood returning to the RV, but the ischemic RV is getting less RCA flow which causes the RV to lose even more contractile force... and the cycle worsens in a circular fashion until someone does something to stop the cycle.

Vasopressin is life saving in this situation.

Banana nut, BSN, RN, EMT-B

Has 2 years experience.

The problem is they can sometimes be easily missed. Especially to someone newer to reading EKG's, that's when I have usually seen it happen. Not from not getting an EKG first.

This is very true and in this particular situation the sequence of events whet as such: wheeled to room,with crushing chest pain, cool pale diaphoretic----SL Nitro administered before he was even in a gown-----BIG BP DUMP------12lead showing no STEMI, IV fluids and morphine, cardiac enzymes and repeat 12 lead showing STEMI, we then go him on the gourney for code 3 transport and they hung heprin in route. I literally watched him infarc it was very interesting. So it was pretty much a big roll of the dice as to where he was ischemic.

Thank you all for your insight.

~Mi Vida Loca~RN, ASN, RN

Specializes in Emergency Dept. Trauma. Pediatrics. Has 6 years experience.

This is very true and in this particular situation the sequence of events whet as such: wheeled to room,with crushing chest pain, cool pale diaphoretic----SL Nitro administered before he was even in a gown-----BIG BP DUMP------12lead showing no STEMI, IV fluids and morphine, cardiac enzymes and repeat 12 lead showing STEMI, we then go him on the gourney for code 3 transport and they hung heprin in route. I literally watched him infarc it was very interesting. So it was pretty much a big roll of the dice as to where he was ischemic.

Thank you all for your insight.

They gave him Morphine after his BP dumped that much and with it that low?

Yea those Chest pain patients that often match the wall color, never good, once they start vomiting in my experience they will be coding any minute. I have never seen a patient come in with the chest pain and dusky color that did not code within a couple minutes of vomiting, in fact when all the media was covering the Robin Thicke story and they said he started vomiting I told my friend, this isn't going to end well. Again just my experience.

I will already be prepared to do CPR. Thankfully all the hospitals I have worked in except one, had cath labs.

AnnieOaklyRN, BSN, RN, EMT-P

Specializes in ED, Pedi Vasc access, Paramedic serving 6 towns.

Hi,

When a patient is having an inferior MI, you should always do a right sided EKG ( V3, V4, and V5 on the right) PRIOR to giving NTG. The right ventricle is very dependent on after load and preload especially if its infarcting, thus as another poster eluded you should be giving fluids to the patient, not NTG, after you assess lung sounds of course. Also the right sided leads will not have crazy amounts of elevation, and it can be very vague because the right ventricle is a lot smaller than the left ventricle, thus the waves are smaller.

That was rather negligent to begin patient care with NTG before he had an EKG or IV in place! Please don't ever let that happen again. Tell you clinicians to read the research, as NTG has never been proven to lessen morbidity or mortality in MIs! Morphine has been shown to INCREASE mortality. If a narcotic needs to be given, which in most cases it can help calm the patient and take the edge off, Fentanyl should be given instead of Morphine, especially if a STEMI with right side involvement is present.

Please encourage your nurse manager to provide increased education on the management of STEMIs and chest pain patients, as it would seem the knowledge is lacking, or at least that is the picture you are painting.

Annie

Banana nut, BSN, RN, EMT-B

Has 2 years experience.

Here's why NTG is not a good idea when the RV is ischemic from RCA occlusion. Perfusion from the aortic root down the RCA occurs over systole and diastole (unlike the left main where it is only diastole). The NTG increases venous capacitance, holding blood in reserve in the venous system with the ultimate effect being that less blood returns to the RV for processing through the lungs and being delivered to the LV.

This means that LV stroke volume, cardiac output, and S/D blood pressure falls. This causes a fall in aortic root pressure which causes RCA flow to fall to an already ischemic RV...

Now, not only is less blood returning to the RV, but the ischemic RV is getting less RCA flow which causes the RV to lose even more contractile force... and the cycle worsens in a circular fashion until someone does something to stop the cycle.

Vasopressin is life saving in this situation.

This was a great explanation thank you!

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

The problem is they can sometimes be easily missed. Especially to someone newer to reading EKG's, that's when I have usually seen it happen. Not from not getting an EKG first.

That's a good reason why the EKG needs to be read prior to treatment by someone adequately competent at reading ischemic changes and where they are located. Pretty much every ED nurse can recognize a STEMI or obvious arrhythmias, NSTEMI's require a higher level of competency and experience.

Banana nut, BSN, RN, EMT-B

Has 2 years experience.

They gave him Morphine after his BP dumped that much and with it that low?

Yea those Chest pain patients that often match the wall color, never good, once they start vomiting in my experience they will be coding any minute. I have never seen a patient come in with the chest pain and dusky color that did not code within a couple minutes of vomiting, in fact when all the media was covering the Robin Thicke story and they said he started vomiting I told my friend, this isn't going to end well. Again just my experience.

I will already be prepared to do CPR. Thankfully all the hospitals I have worked in except one, had cath labs.

Yeah he came in looking dumpy but ended up not coding. He got to the cath lab and was saved! It was a cool experience, he was in and out in less than 15 minutes.

That's a good reason why the EKG needs to be read prior to treatment by someone adequately competent at reading ischemic changes and where they are located. Pretty much every ED nurse can recognize a STEMI or obvious arrhythmias, NSTEMI's require a higher level of competency and experience.

Good point, as usual...you're really a credit to this site... anyway...

STEMI is such a misnomer and leads to confusion. RCA ischemia can lead to profound ST elevation in the anterior leads (as well as the lateral ones) but is a different entity entirely than an inferior or inferio-septal (LV) wall MI.

ST elevation does not mean STEMI in the sense that the LV is involved. IMHO we should use a different term.

~Mi Vida Loca~RN, ASN, RN

Specializes in Emergency Dept. Trauma. Pediatrics. Has 6 years experience.

That's a good reason why the EKG needs to be read prior to treatment by someone adequately competent at reading ischemic changes and where they are located. Pretty much every ED nurse can recognize a STEMI or obvious arrhythmias, NSTEMI's require a higher level of competency and experience.

I don't disagree. But that's not always the case. Sometimes on a night shift there is one doc there and you find out they aren't as good at recognizing a RVI. Or the doc that picks up the patient misses it, or doesn't believe the nurse when it's pointed out. Many variables can come into play. But yes in an ideal situation you have time to do an EKG and have someone very good at reading them and avoid a situation like this all together.

~Mi Vida Loca~RN, ASN, RN

Specializes in Emergency Dept. Trauma. Pediatrics. Has 6 years experience.

Yeah he came in looking dumpy but ended up not coding. He got to the cath lab and was saved! It was a cool experience, he was in and out in less than 15 minutes.

Always nice when it works out that way. Charge likes it too. By the time I am back to my zone from running to the cath lab there is already a new patient waiting for me in the empty room. lol

NICU Guy, BSN, RN

Specializes in NICU. Has 5 years experience.

I have never seen a patient come in with the chest pain and dusky color that did not code within a couple minutes of vomiting, in fact when all the media was covering the Robin Thicke story and they said he started vomiting I told my friend, this isn't going to end well.

You mean his dad, Alan Thicke?

~Mi Vida Loca~RN, ASN, RN

Specializes in Emergency Dept. Trauma. Pediatrics. Has 6 years experience.

You mean his dad, Alan Thicke?

Yes I did mean his pops! When I was typing it I was thinking about Robins song and never realized I typed his name instead.