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Sdiver · 11-19-2013, 19:58

Okay guys, I'm gonna close this one out and wrap up a few points.
Here's the diagnosis and treatment plan for this Pt.

This Pt. is having an Inferior wall MI as seen in Leads II, III and aVF, with reciprocal changes on the Lateral side as noted in Leads I, aVF and V6). This patient is in cardiogenic shock because the right ventricle has been taken out and there is no forward movement of blood through the heart. These patients are preload dependent due to Starling's Law of the heart.

-- This patient is lacking preload due to the inferior MI and his exam is consistent with RIGHT sided heart failure (JVD and swollen ankles) that is often seen in inferior MIs. He has trace crackles in his lungs, but this should not be a distractor. He needs fluids and lots of them, place on NS or Lactated ringers on a pressure infuser. This is due to Starling's Law of the heart which states that the strength of the heart's systolic contraction is directly proportional to its diastolic expansion. More fluids = more preload = more contractility = less failure.

-- This patient needs a pressor as well as he is showing signs of severe hypoperfusion. Levophed (norepinephrine) is currently the preferred pressor in all cases of hypoperfusion / shock, however not all agencies have this. Dopamine is a good alternative if that is the pressor available to you. You must improve this patient's perfusion, his heart is dying from the MI and the lack of coronary artery perfusion pressure is not helping.
http://www.nejm.org/doi/full/10.1056/NEJMoa0907118

-- Do you employ air transport? It depends on the resources the helo will bring. If the helo has a higher level of care (i.e. RN / MD or pressors like levo / anticoagulants like heparin) then this might be a good option. But remember that CPR in a helo is not an easy task. If your ground ambulance has reasonable resources, rapid ground treatment may be just as efficacious.

-- Alternatively, there is a community hospital nearby. Certainly the patient could be stabilized there, given TPA or TNK, or started on pressors and rapidly flown after it is clear that maximal therapy has been initiated to decrease the risk of in-flight cardiac arrest.

-- If pressors are to be given, IO is the best route as IO is considered equivalent to a central line.

-- O2 .... His O2 sats are at 92% on 4L via NC, would a NRB at 15L do anything for him? I've always been a big proponent for higher O2 delivery (it's due to the diver in me) but with this talk of free radicals, keeping his sats right at 92% is fine. But that doesn't mean you should completely r/o higher O2 with the type of fluids given. NS doesn't have the same O2 carrying capacity as plasma or RBCs have, so keep that in the back of your noodle.

-- Also, if this Pt. "crashes" prepare to intubate and BVM with high flow O2.

Thanks for playing, we'll have nice parting gifts for you as you leave.

**Trapper ... I'll take that nipple ring off your hands due to my above boneheaded comment, which was caught by SS.

11-19-2013, 19:58	#28
Sdiver Area Commander Join Date: Feb 2004 Location: The Black Hills of SD Posts: 5,944	Okay guys, I'm gonna close this one out and wrap up a few points. Here's the diagnosis and treatment plan for this Pt. This Pt. is having an Inferior wall MI as seen in Leads II, III and aVF, with reciprocal changes on the Lateral side as noted in Leads I, aVF and V6). This patient is in cardiogenic shock because the right ventricle has been taken out and there is no forward movement of blood through the heart. These patients are preload dependent due to Starling's Law of the heart. -- This patient is lacking preload due to the inferior MI and his exam is consistent with RIGHT sided heart failure (JVD and swollen ankles) that is often seen in inferior MIs. He has trace crackles in his lungs, but this should not be a distractor. He needs fluids and lots of them, place on NS or Lactated ringers on a pressure infuser. This is due to Starling's Law of the heart which states that the strength of the heart's systolic contraction is directly proportional to its diastolic expansion. More fluids = more preload = more contractility = less failure. -- This patient needs a pressor as well as he is showing signs of severe hypoperfusion. Levophed (norepinephrine) is currently the preferred pressor in all cases of hypoperfusion / shock, however not all agencies have this. Dopamine is a good alternative if that is the pressor available to you. You must improve this patient's perfusion, his heart is dying from the MI and the lack of coronary artery perfusion pressure is not helping. http://www.nejm.org/doi/full/10.1056/NEJMoa0907118 -- Do you employ air transport? It depends on the resources the helo will bring. If the helo has a higher level of care (i.e. RN / MD or pressors like levo / anticoagulants like heparin) then this might be a good option. But remember that CPR in a helo is not an easy task. If your ground ambulance has reasonable resources, rapid ground treatment may be just as efficacious. -- Alternatively, there is a community hospital nearby. Certainly the patient could be stabilized there, given TPA or TNK, or started on pressors and rapidly flown after it is clear that maximal therapy has been initiated to decrease the risk of in-flight cardiac arrest. -- If pressors are to be given, IO is the best route as IO is considered equivalent to a central line. -- O2 .... His O2 sats are at 92% on 4L via NC, would a NRB at 15L do anything for him? I've always been a big proponent for higher O2 delivery (it's due to the diver in me) but with this talk of free radicals, keeping his sats right at 92% is fine. But that doesn't mean you should completely r/o higher O2 with the type of fluids given. NS doesn't have the same O2 carrying capacity as plasma or RBCs have, so keep that in the back of your noodle. -- Also, if this Pt. "crashes" prepare to intubate and BVM with high flow O2. Thanks for playing, we'll have nice parting gifts for you as you leave. Trapper ... I'll take that nipple ring off your hands due to my above boneheaded comment, which was caught by SS. __________________ Non Sibi Sed Suis** _____________________________________________ It's Good To Be Da King !!!! Just ask NDD !!!! Last edited by Sdiver; 11-19-2013 at 20:04.
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