Heart attack stuff

nurse4theplanet, RN · Jan 15, 2007

Well, I'm a new grad and it's a very general question but I'll give it a shot...

Any decrease in cardiac output ...damage from the MI, ischemia, arrythmias

Any loss of volume...like if the pt is on blood thinners and is having active bleeding

Spatialized · Jan 15, 2007

Let's see here... just thinking, not a definitive answer...

Cardiogenic shock - the pump (i.e. the heart) has failed and is unable to pump well enough to maintain perfusion. The damage can be caused by the MI itself, depending on the size and location (is the LAD involved? which vessel is blocked?) will contribute heavily to the scope of pump failure. Other problems like having a low EF (ejection fraction), as seen in cardio myopathy/heart failure can contribute to this.

Change in position (orthostasis) - saw a stabbing victim in the ER go totally pasty pale white on us when we repositioned him from an obvious drop in blood pressure.

Meds - any vasodilators, when given in too large amounts, have the obvious effect. Or things like a beta blocker that will slow the heart down if given in cases of an inferior wall infarct that causes the patient to brady down...

Arrythmias - any rhythm that does not adequately perfuse, brady, VT/VF etc...

hope this helps!

Dinith88 · Jan 16, 2007

Cardiogenic shock - !

Thats the answer to your question.

To put it as plainly as possible, the 'pressure' of the circulating blood in your vessels needs to be maintained at an appropriate level(pressure). If 'hypotensive' (pressure in your vessels falls) BECAUSE of a heart attack, it is due to a weak 'pump'...This weak 'pump' is caused by a lack of blood supply (from the blockage). The heart muscle becomes 'sick', 'starved', 'weak'...and eventually dies. This compromised 'pump tissue' is unable to function properly...which means it is unable to keep the pressure 'up'...(which translates into a low blood pressure)...

You can forget all the other stuff. If your pump isnt working, you cant move blood.

HOpe yor EMT class goes well...

banbulance · Jan 29, 2007

Thank you once again for all your help! And once again you too Dinith88 you have helped me as well. My Emt class is going great...lota study which I don't mind exercising the old noodle:pumpiron: See you next round, I'm sure I'll have more questions.

Cheers!

Banbulance

SEOBowhntr · Jan 30, 2007

Thank you once again for all your help! And once again you too Dinith88 you have helped me as well. My Emt class is going great...lota study which I don't mind exercising the old noodle:pumpiron: See you next round, I'm sure I'll have more questions.
Cheers!
Banbulance

Ban,

Depends on the type of MI. Inferior/Posterior MI's with associated Right Ventricle involvement, have a very nasty and life-threatening response to Nitroglycerin. If the patient were an Inferior/Posterior MI, and was on NTG, then there may be your answer. If the patient is a large MI, not an Inferior/Posterior, then Cardiogenic Shock may be a more likely cause, as well as Rhythm abnormality. With just that small amount of information, it is difficult to guess. But there is a little more info to chew on!!!

Dinith88 · Jan 30, 2007

Ban,
Inferior/Posterior MI's with associated Right Ventricle involvement, have a very nasty and life-threatening response to Nitroglycerin.

BAn...once again we get into the grey area of 'relativity'...

If you have inferior mi (w/rv involvement) you COULD POTENTIALLY have problems with nitro (or other drugs)...the key word being POTENTIALLY.

It would be wrong for you to take away from this thread a blanket statement that inferior wall mi's have a 'nasty life-threatening response to nitro...' Nitro is a gold-standard drug when treating cardiac ischemia...even in inferior MI's!! You just have to watch them close and go gently with the nitro (and other drugs). It's just something to keep in the back of your mind when treating these folks.

SEOBowhntr · Jan 30, 2007

BAn...once again we get into the grey area of 'relativity'...
If you have inferior mi (w/rv involvement) you COULD POTENTIALLY have problems with nitro (or other drugs)...the key word being POTENTIALLY.
It would be wrong for you to take away from this thread a blanket statement that inferior wall mi's have a 'nasty life-threatening response to nitro...' Nitro is a gold-standard drug when treating cardiac ischemia...even in inferior MI's!! You just have to watch them close and go gently with the nitro (and other drugs). It's just something to keep in the back of your mind when treating these folks.

Obviously, you should read up a bit more on NTG, Dinith. You see, NTG is very much so contraindicated for inferior MI's, esp with a suspicion of RV involvement. Part of the reason we do Right-sided EKG's. "RELATIVE" contraindications for NTG.....HOCM, Inf MI w/ RV involvement, Cardiac Tamponade, HR

You see, until you've seen a patient CRASH & BURN because someone gave NTG without doing an appropriate assessment, you really don't have a healthy respect for the DEVASTATING effects it has when used inappropriately. M-O-N-A, could kill ya, if used inappropriately.

Sublingual nitroglycerin should be given, unless the patient is hypotensive or bradycardic, has taken sildenafil within the last 24 hours, or there is a strong suspicion of right ventricular infarction.
ECG: Obtain within 10 minutes of presentation and follow-up with a serial ECG. A right-sided ECG should be performed if a standard ECG suggests an inferior wall MI.

Dinith88 · Jan 30, 2007

....,

SEOBowhntr · Jan 30, 2007

dinith,

actually, one of the things that our facility stresses is the correct interpretation of ekg's and ensuring that we use appropriate meds in appropriate circumstances. i've many times argued with poorly informed physicians, and gotten apologies after they were shown to be wrong. in my 11+ years of cardiac care, i've seen a lot of different things. probably worst case scenario with inappropriate use of ntg was a patient who was hypertensive, with inferior changes, who went asystolic after a ntg gtt was initiated and titrated for the second time from 20ug to 30ug. the patient had a prox rca that was 95% occluded, involving his rv, and the second titration up of ntg was just enough to take away his right sided filling pressures, and send him over the edge. actually this does pertain to the original question, because the inferior mi is the one that will cause the major hypotension very quickly. remember this is an emt, 15 minutes or so to the hospital most of the time, not 2 hours. and likely a person who is going to be treating the patient with ntg very early. other even more severe options would be things like rupture of papillary muscle, but not real likely in the setting an emt would be dealing with. which, by the way, is probably worse to watch and a horrible inferior mi!!!

the thing with inferior mi's is that you give the nitro gently to see if they tolerate it. if the are unable to tolerate it (meaning they become markedly hypotensive), you stop the nitro and give a fluid bolus (this usually works). this would be (usually) how you would 'suspect' rv involvement...not because the ecg shows inferior elevation. and another thing, not all rv-mi's act this way...mostly just the extensive ones. so again...we get into 'potential' complications. to state (like you did) that all rv mi's (which insinuates all inferior mi's) have 'nasty life-threatening complications' is a little misleading.

it is quite concerning that you advocate practice that potentially puts patients at risk. such as "gentle" administration of ntg, to see if a pt. tolerates it, rather than a quick diagnostic check, which takes less than 2 minutes. not sure where you work, but we use rt-sided ekg's on most of the pts. who present with inf. changes, esp. if they show reciprocal changes in the lateral leads(reciprocal changes, indicating the the area of ischemia is opposite of that lead). on my unit, all pt's who report chest pain, will have an ekg done and compared to their previous, and a set of vital signs, prior to any administration of ntg, morphine, or anything else. for a couple of reasons, first, if you are doing a diagnostic procedure, it makes more sense to do that diagnostic procedure prior to administering a medication to alter that diagnostic procedure. kind of like giving a few doses of ancef and then drawing blood cultures, don't make sense. secondly, if the patient is mildly hypotensive, bradycardic, or shows inferior changes, esp. those suggestive of rv ischemia, a physician is notified prior to administration of ntg, to ensure he agrees with that treatment in that specific patient's situation.

might not seem like the the way you'd do things, but it works quite well here, and we are a top 10% hospital in the country, so it would seem to be "evidence-based" practice. :idea:

the second bolded part of you post is a bit inaccurate, but sometimes, for argument's sake people tend to do that, i just wanted to highlight it so you could go back and re-read slowly to understand what i'd said.

now at this point, we've gotten way beyond the question, but i thought maybe a little more background would help you understand better.

Dinith88 · Jan 30, 2007

.....

SEOBowhntr · Jan 30, 2007

???? something about this statement says alot about you....
.......
( and i'll try VERY HARD NOT TO read your next post.... so there!! :) )

Yeah, it shows I will argue with anyone who doesn't know what they're talking about, in efforts to protect patients. A personality trait I am quite proud of, as I've always strived to do the "RIGHT" thing, even in the face of nasty consequences.

As to the end of the post, I suppose I can only be relieved there wasn't some silly, "I'm rubber and your glue....." comment attached. But there's always time I suppose.

Oh, and about the A-Fib can't be atrial paced, I posted some specific directions on another thread earlier, you may find it quite informative. Keep and open mind, that way you can capture each and every learning opportunity, rather than stubbornly refusing to change.

And yes, the resultant hypotension probably was due to an inferior MI with RV involvement, which may or may not have been mistreated. If the problem was related to a left-sided problem, acute dyspnea would likely also have been a symptom. Not that it's really relevant at this point.....