Diagnosing Right Sided M.I. w/o ECG's

[jasperfire]

In Alberta we are allowed in the EMT (PCP) scope to administer Nitro for M.I.'s/Ischemic chest pain. I'm all fine and content with the protocols, administration and doses except for one "relative" contraindication. This contraindication states that Nitro administration should be seriously reconsidered for pateints experiencing a right sided M.I. Unfortunately in Alberta we don't have the ability to diagnose and interpret 12 or 15 lead ECG's at our level. I want to be able to recognize right sided M.I. symptoms through physical findings. I know this may open up a big can but I'm curious as to what others would do in these circumstances. So far I have ankle/peripheral edema, clear lung sounds and flat neck veins. My instructors were really helpful but they said that without the ability to diagnose a 12 or 15 lead it could be quite hard. I don't want to find a reason to withhold lifesaving interventions by any means but I want to be a informed, aware and thorough practitioner. Any comments, concerns or questions for a somewhat concerned/confused student?

[dentedhead]

In Alberta we are allowed in the EMT (PCP) scope to administer Nitro for M.I.'s/Ischemic chest pain. I'm all fine and content with the protocols, administration and doses except for one "relative" contraindication. This contraindication states that Nitro administration should be seriously reconsidered for pateints experiencing a right sided M.I. Unfortunately in Alberta we don't have the ability to diagnose and interpret 12 or 15 lead ECG's at our level. I want to be able to recognize right sided M.I. symptoms through physical findings. I know this may open up a big can but I'm curious as to what others would do in these circumstances. So far I have ankle/peripheral edema, clear lung sounds and flat neck veins. My instructors were really helpful but they said that without the ability to diagnose a 12 or 15 lead it could be quite hard. I don't want to find a reason to withhold lifesaving interventions by any means but I want to be a informed, aware and thorough practitioner. Any comments, concerns or questions for a somewhat concerned/confused student?

I am not familliar with a "right sided MI" other than vitals and Hx contraindicating nitro use there really isnt any way.

The only absolute nitro = the ultimate piss poor outcome, i recall is if it is an anterior wall infarct.... aka the widowmaker.This is where the ability to understand and just not take vitals seperates the good clinician from the rest.knowing presentation is half the battle.Your PQRST and vitals can help immensly.

Being a FF now,i am just an IV pole or BLS provider...Basic Lift Support guy!

Dentedhead

[jasperfire]

DH,

Thanks for the quick reply. I know that that might have sounded vague so I'll quote verbatim from our formulary from the Alberta College of Paramedics Nitro formulary under "precautions":

"Right Ventricular MI patients are sensitive to Nitroglycerine resulting in hypotension (which may increase infarct size). Nitro SL should not be administered in this circumstance"

What's a guy to do? OPQRST and SAMPLE work really well like you wrote and are essential for your Hx and Tx but am I just SOL trying to figure this one out at my level of care? Like I wrote before it's a can of worms and I don't mean to get too technical but this is one thing that is really nagging me....

[WolfmanHarris]

PCP's where I work have 12 and 15 lead acquisition and interpretation so I have to dig deep into my memory on this one (and will hit the books to confirm when I'm not in bed). Usually I just look for ST elevation in II, III or aVF and then do a modified 12 lead to rule out. The reason NTG is contraindicated in RVMI is that the right ventricle is particularly preload dependent. When the NTG drops preload you see a profound drop in BP vs. other AMI's resulting in poor perfusion and reflex tachycardia increased myocardial oxygen demand. All bad things.

Now as for S&S for RVMI... this is a total WAG, but I want to say normo- to relatively hypotense, clear lung fields and kussmaul's sign (JVD w/ respiration).

I'll try to remember to hit the books tomorrow to confirm.

[jasperfire]

Mr. Harris, that's the kind of answer I was looking for. Thanks for the help and that will be something to look out for. It's good to know that answers are out there to be found. I'd rather figure all this out now rather than on practicum.

Thanks to all and be safe out there.

[northernmedic]

There are no absolutes but people with RVI often present with hypotension (obvious NTG contraindication) or borderline BP and bradycardia. I would avoid giving NTG to someone with a borderline BP say 106/48 or something in this situation even if it may be allowed by your "protocol". Remember, there is no evidence to show that NTG improves outcomes in acute infarcts. The most important interventions are ASA administration and prompt transport to a facility capable of some form of reperfusion. RVI is usually not treated with fibrinolytics so hopefully you have your RVI in the vicinity of a cath lab. Are there cath labs outside Edmonton and Calgary in AB?

[CanuckEMT]

One good little tip for recognizing an RVI without the ability to do a 12 lead with V4R is looking for 3 common signs that present in this condition.

Bradycardia, Barfy(Nausea/Vomiting), Blood Pressure(Hypotension).

You can also do a modified chest lead (MCL1 i believe) with a 3 lead set up to look at the right side of the heart. It's not diagnostic but if there is ST elevation in Leads 2, 3 and your MCL 1 then i would stay away from Nitro and think of small fluid boluses in the 250 ML range to treat the hypotension.

MCL 1 you place the Red lead on the right side of the chest, the black on the left and the white can stay on the right. It's been quite a while since I have done one of those.

[jasperfire]

Now that I've absorbed all of that I'd just like to write a quick thank you to all who replied. Once again it good to know that there are resources like this out there. All the best, be safe and keep your stick on the ice.
Cheers, Jasper