Strong work all.
Trapper John, I like your wide differential. I know many docs would not have initially thought about hyperkalemia and it should be considered anytime you see funky QRS or T waves. Medicine has many "great masqueraders" and hyperkalemia is one of them and doesn't always show up as classic peaked T waves or simple wide QRS.
As a learning point to all, as stated this is an inferior wall MI and as such it is one of the instances where nitrates (e.g. nitroglycerin) could kill the patient (bottom out the blood pressure). Also, as far as field management, patients in cardiogenic shock with flash pulmonary edema are some of the most difficult patients to manage.
adal, I agree with all you said besides some minor points which may be practice/location/or style specific. It's always good to see how other professionals are doing it. It sounds like I could learn a lot from you when it comes to logistics alone, thank you. Since we're all here to learn from each other here's my 2 cents.
Since this is cardiogenic shock fluids may or may not help. As the patient is showing signs of pulmonary edema I would be very cautious with fluids as they may worsen the patient's pulmonary edema. Small test bolus of 250-500 cc would be a good starting point. If pressure improves without worsening hypoxia you may be ok for another bolus. If intubated and oxygenating well it's not as much concern but for a hypotensive patient with an unsecured airway it may cause a disaster (I know I'm preaching to the choir). For that reason this is one of the
very few instances I'd go straight to a pressor, specifically levophed (norepinephrine). We don't carry levophed prehospital in our state expect for CC transports. We have dopamine which I agree has more risk of arrhythmias but has inotropic effects. Phenylephrine is alpha 2 and only and causes vasoconstriction so your patient's heart is going to have have more work to do without any added pump support (not good for a heart that already is not receiving enough oxygen). Dobutamine is an inotrope (pump support) so it will increase contractility but it causes vasodilation also so often times it actually drops BP at first. Epinephrine would increase heart rate too much worsening ischemia.
In our trucks and birds we have dopamine because Levophed is supposedly not as stable in field conditions. However, levophed is the recommended first line pressor in cardiogenic shock. This is a fairly new recommendation.
Too much? Sorry just got off a shift and I'm still jacked up on coffee
