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RescueNet 12-Lead by ZOLL Medical Corporation at EMS World Expo 2011

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Photo credit: EMSWorld.com

ZOLL Medical Corp has some smart people working on their products and a couple of innovations were standouts at EMS World Expo 2011.

The first is the RescueNet 12-Lead.

For a long time I've been preaching about the importance of making 12-lead ECG transmission simple, cost-effective, and interoperable with existing technologies.

As our good friend Ivan Rokos, M.D. said to heartwire back in April 2009:

"It seems incredible that we can email a photograph around the world, but we haven’t yet found an easy way of transmitting an ECG to a nearby hospital."

The reality is that the technology was always there but industry has had little incentive to make it cost-effective or interoperable. Better to charge subscription fees for ECG transmission and make sure that customers are locked into proprietary software. That way you're more likely to continue using Brand X when it's time for a monitor upgrade. After all, now you're committed to a platform. A solution.

In what seems a huge leap of faith, ZOLL Medical Corporation has unlocked the doors. Here's Amy Smith, ZOLL's Director of Data Integration on the EMS Leadership podcast.

"RescueNet 12-Lead is the first fully web-based 12-lead management system. No proprietary software to install. All we need is an internet connection and a web browser to allow EMS and hospitals quick, rapid access anywhere within the world to their critical 12-lead data…ZOLL is offering this service at no cost to EMS and hospitals as an extension of the care we provide through our defibrillator devices." 

When asked if other monitors could use this platform for ECG transmission:

"Absolutely. ZOLL has architected this with open architecture in mind. We will be making available to all of the defibrillator vendors in this market space our APIs that will give them the opportunity at no cost to them to also transmit their 12-lead data into the system. So where we have STEMI regions that use multiple devices…they have an opportunity to use a single software system to receive and manage those 12-leads regardless of their defibrillator devices." 

I was so impressed with this that I mentioned it to Jon Cloutier (Marketing Manager for EMS) who said, simply, "We listened." 

Yes, Jon. You did! 

I went over to the ZOLL both and watched as Amy transmitted a 12-lead ECG from a ZOLL M-series monitor to the RescueNet 12-Lead with a simple cell phone connection.

I said, "Looks good! Can you forward it to my email?" She said, "Absolutely!" Moments later she had entered my email address into the computer and my Droid X vibrated in my pocket.

The 12-lead was attached as a 98K .pdf document.

Piece of cake! 

You couldn't ask for much more. It's nice to see ZOLL step up to the plate and solve this problem. Clearly ZOLL is looking at regional STEMI systems and seeing customers to be served rather than cows to be milked. That's a huge gesture of good faith on their part and will go a long way toward building trust between ZOLL and their customer base.

Bravo! 

See also:

Amy Smith from ZOLL on RescueNet 12-Lead with EMS Leadership Podcast

Jon Cloutier From Zoll Shares Innovations at EMS Today 2011

Posted by on September 28, 2011 • Filed under: ems-topics, patient-management • Tagged: , , ,

ReadyLink 12-Lead ECG by Physio-Control (update)

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Now that I'm starting to get caught up on my regular duties after my recent trip to EMS World Expo 2011 there are a few products I'd like to highlight from the trip.

The first is Physio-Control's ReadyLink 12-Lead ECG.

You may recall that Physio-Control allowed ems12lead.com the privilege of announcing the launch of this product back at the beginning of August.

One thing I know now (that for whatever reason I didn't understand at the time) is that the ReadyLink 12-Lead ECG has a monitor screen! 

I snapped this photo with my Droid X on the show floor at EMS World Expo 2011.

Apparently the monitor screen is so that basic EMTs can tell if there is wandering baseline, loose lead or muscle tremor artifact. However, to me this is a big deal!

I can imagine the ReadyLink 12-Lead ECG being placed along side AEDs on commercial jet airliners. At any rate, I just wanted to clarify that the ReadyLink 12-Lead ECG has a monitor screen for anyone who, like me, thought it did not.

You will recall that when we announced the product launch we called the the ReadyLink 12-Lead ECG a "game changer" and so it is for rural systems that can now be tied into existing systems of care that are already using the LIFENET.

This is especially important in light of recent evidence that while PCI centers have done an amazing job shortening door-to-ballon times since the advent of the D2B Alliance, there are still significant delays for STEMI patients transferred from non-PCI hospitals.

That shouldn't be a surprise to anyone with a special interest in regional systems of care for acute STEMI.

More than 34% of patients transferred for PCI had a delay in total treatment time (> 120 minutes from presentation at initial hospital). The reasons for the delay included:

  • Awaiting transportation (26%)
  • Emergency department delays (14%)
  • Diagnostic dilemma (9%)
  • Cardiac arrest (6%)

Keep in mind this does not include prehospital time prior to presentation at the initial hospital.

To measure these delays correctly would require that we measure from 9-1-1 call to reperfusion. But let's put that issue aside for the time being.

The point is that 40% of the delays from referring hospitals could be completely eliminated if EMS was capable of identifying acute STEMI in the fiend and bypassing them altogether in the first place.

Even without that there are opportunities for improvement for the transferring hospitals and EMS needs to be a part of that solution (since 50% of acute STEMI patients self-report to non-PCI hospitals).

There is no acceptable reason that an acute STEMI patient should be sitting around waiting for a transport ambulance if the local 9-1-1 system has a unit available.

That's a totally legitimate emergency call and EMS systems that "don't do interfacility transport" need to reconsider their policy for life-threatening emergencies (like acute STEMI) where every minute counts.

Posted by on September 25, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , ,

12-Lead ECG Challenge app now available for Android and Apple iOS

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In a previous review of the ACLS Review app by Limmer Creative I announced that I was working together with Limmer Creative to create a 12-Lead ECG Challenge app.

I'm pleased to announce that the app is now available for Android and Apple iOS! The product made its debut at EMS World Expo 2011 in Las Vegas.

As chance would have it I was there for other reasons and my good friends Ted Setla and Justin Schorr of the First Responders Network were kind enough to interview me about the app.

Here's how it works.

The app has 150 12-lead ECGs that were taken from actual patient encounters.

The user of the app is given a brief scenario. For example, a 95 year old female with a chief complaint of altered level of consciousness.

You can tap on the little magnifying glass to enlarge and expand the 12-lead ECG.

Once you think you know the answer you tap the ANSWER button, the card flips, and the answer text comes up along with (in most cases) an ANSWER graphic.

In this case we are dealing with a bifascicular block (right bundle branch block and left anterior fascicular block) as evidenced by the supraventricular rhythm with a QRS duration > 120 ms, the RBBB morphology in lead V1 and a left axis deviation (QRS complexes positive in lead I and negative in leads II and aVF).

The 12-Lead ECG Challenge app strongly emphasizes acute STEMI and the STEMI mimics (including benign early repolarization, left ventricular hypertrophy, paced rhythm, left bundle branch block, pericarditis, left ventricular aneurysm, hyperkalemia, hypothermia, WPW and Brugada) so it's a great study tool to help paramedics minimize false positive cardiac cath lab activations.

For example, here's an answer graphic that demonstrates the relevant findings for a patient whose 12-lead ECG was consistent with pericarditis.

The app is priced at $4.99, a bargain when you consider that online 12-lead ECG tutorials start at around $45.00. Our goal was to appeal to a world-wide market and make it affordable for everyone.

You can download it here:

(Android)  (Apple iOS)  (Web Based)

If you like the app (or even if you don't) feel free to leave a review, here or at the Android Market or Apple Store.

See also:

The Only 12-Lead ECG App You’ll Ever Need – The Social Medic

Posted by on September 23, 2011 • Filed under: ems-topics, patient-management • Tagged: , , ,

Conclusion to 88 year old male CC: Chest pain

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This is the conclusion to 88 year old male CC: Chest pain. You may wish to review the previous post for the history and clinical presentation.

Let's take another look at the 12-lead ECG.

Now with the computerized interpretation.

This 12-lead ECG shows bifascicular block and is very suspicious for acute STEMI.

The first thing that jumps out at me when I look at this 12-lead ECG is the concordant T-wave in lead V2.

With right bundle branch block (RBBB) the T-wave should be deflected opposite the terminal (last) wave of the QRS complex. Because the QRS complex ends in an R-wave the T-wave should be negative. However, in this case it is positive. This is sometimes referred to as "pseudo-normalization" of the T-wave with RBBB. You will also note that the ST-segment is slightly elevated.

Now let's take a closer look at the high lateral leads I and aVL.

Do not let your eye be fooled! I have noticed that in the setting of RBBB the S-wave is often "lifted" when ST-elevation is present. That can create the illusion that the ST-segment is isoelectric. In this case, if you look carefully you will see that the J-point is clearly elevated.

It's debatable as to whether or not 1 mm of ST-elevation is present in the high lateral leads but some ST-elevation is present. Remember, the conventional criterion of 1 mm of ST-elevation in 2 or more contiguous leads is a gross oversimplification. However, computerized interpretive algorithms obey the rules and this ECG has not triggered the ***ACUTE MI SUSPECTED*** message (yet).

When ST-elevation is present in the high lateral leads (I and aVL) we should inspect the inferior leads (II, III and aVF) for reciprocal changes. The converse is also true.

ST-depression is present in leads II, III and aVF. If you're not sure of the exact location of the J-point in leads II and III you can find the J-point in lead I and draw an imaginary line straight down to help you find your landmarks. This finding is subtle (most obvious in lead aVF) but to me this is the strongest evidence that the concordant T-wave in lead V2 and slight J-point elevation in leads I and aVL are pathological.

It can't be repeated often enough. When looking at any ECG abnormality "consider the company it keeps." We might blow off a single lead showing a concordant T-wave. We might blow off a single lead showing a slight amount of J-point elevation. We might blow off a single lead showing an inverted T-wave or ST-depression, but put them all together and a picture starts to emerge.

In this case the picture that emerges is a high-risk patient who is almost certainly experiencing an acute coronary syndrome! 

Unfortunately, this crew obtained only one 12-lead ECG and did not recognize these abnormalities. One of the best quotes I've heard about serial 12-lead ECGs came from Tim Phalen. He said, "Taking a single 12-lead ECG is like taking a single photograph of Old Faithful. Is it a geyser, or is it a hole in the ground?" 

One imagines that if this ECG were to have been repeated it would have shown changes to suggest the dynamic oxygen supply vs. demand characteristics of ACS.

On the plus side, this ECG was transmitted to the hospital and the ED physician found it to be suspicious. The 12-lead ECG was repeated in the emergency department (we do not have a copy of this ECG) and a "Code STEMI" was called. The patient was taken to the cardiac cath lab. We do not have a copy of the cath report. However, we do know that for some reason the cath was unsuccessful and the patient was sent to the OR for a 3-vessel CABG.

Diagnosis: Acute ST-elevation myocardial infarction

Posted by on September 18, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

Syncope and sudden death in student athletes Part 2 – EMS 12-Lead podcast Episode #2

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EMS 12-Lead podcast – Episode #2 – Syncope and sudden death in student athletes Part 2

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Podcast: Play in new window | Download

In this episode Tom Bouthillet and David Baumrind are joined by Trudie Lobban of STARS (Syncope Trust And Reflex anoxic Seizures) — a not-for-profit organization that works together with individuals, families and medical professionals to offer support and information about unexplained loss of consciousness (syncope).

Trudie Lobban
Photo credit: http://www.atrialfibrillation-us.org

To learn more about STARS see the following links:

Syncope Trust And Reflex anoxic Seizures (STARS) – International 

Syncope Trust And Reflex anoxic Seizures (STARS) – U.S.

Syncope Trust And Reflex anoxic Seizures (STARS) – International on Facebook

Syncope Trust And Reflex anoxic Seizures (STARS) – U.S. on Facebook

Related content:

EMS 12-Lead podast – Episode #1 – Syncope and sudden death in student athletes Part 1

Posted by on September 15, 2011 • Filed under: ems-topics • Tagged: , , , , ,

81 year old female CC: Chest Pain – Conclusion

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This is the conclusion to 81 year old female CC: Chest Pain.

Due to a significant language barrier, we were unable to obtain a useful medical history. Yet this case highlights the importance of a good scene assessment to gain additional information of clinical importance.

First, let's examine the patient's 12-Lead ECG.

We have a bradycardic, wide complex rhythm with no visible P-waves. It is also unremarkable for ischemia or infarction. Given the rate, we have a few possibilities:

  • Junctional rhythm with RBBB
  • Idioventricular rhythm

In the field, the distinction between these two possibilities is entirely academic. Our treatment modality relies instead on our patient's presentation.

As our patient is asymptomatic, of interest in this case is one of our patient's medications.

Digoxin is commonly prescribed for atrial fibrillation and atrial flutter. It works by increasing the refractory period of the AV node, effectivily slowing AV nodal conduction and the ventricular rate. It follows naturally that digitalis toxicity commonly includes bradyarrhythmias and AV nodal blocks. 

A second look at the 12-Lead ECG shows fibrillatory waves in V1 and V2, consistent with underlying atrial fibrillation. Likely our patient is suffering from digitalis toxicity with atrial fibrillation, a 3rd degree AV block, and an idioventricular escape rhythm. Other high risk differentials include myocardial infarction and hyperkalemia.

The paramedics on this call began with a working diagnosis of digitalis toxicity, performing serial 12-Leads enroute to identify ischemic changes. They started an IV, applied combo-pads to the patient, and closely monitored the patient until they arrived at the receiving facility.

At the receiving facility, blood labs were drawn and the patient's digoxin levels returned at 3.0 ng/mL, which is above the normal therapuetic range of 0.8-2.0 ng/mL. The patient's troponin levels remained below 0.4 ng/mL.

The patient was diagnosed with acute digitalis toxicity and admitted for observation. The patient was scheduled for a pacemaker implantation and lost to follow-up by the EMS agency.

Posted by on September 13, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , ,

68 year old male CC: Chest Pain – Conclusion

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This is the conclusion to 68 year old male CC: Chest Pain.

When we last left off, our patient was sitting outside a convenience store with a sensation of, "somebody punching me in the chest".

Our patient had a fast, irregular pulse, and we had acquired a rhythm strip and a 12-Lead ECG.

The rhythm strip shows a grossly irregular, narrow complex tachycardia with a rate between 120 and 160. The R-R intervals and TP segments are constantly changing as well. This is atrial fibrillation with a rapid ventricular response, also known as uncontrolled atrial fibrillation.

When dealing with AF and RVR it is important to determine if this is an acute onset or rather chronic atrial fibrillation exacerbated by some underlying problem. As our patient is a poor historian, this is difficult to say.

"Healthy as a horse," he exclaims. Let's evaluate that statement in the context of his 12-Lead ECG (with the computerized interpretation added).

Quick Thinking - Initial 12-Lead with Interpretation

As most readers correctly noted, we have atrial fibrillation with a Right Bundle Branch Block and a rapid ventricular response. An interesting finding is the apparently narrow QRSd in the limb leads due to the frank ST-depression. This highlights the importance of seeing the problem from more than one lead!

Also, most spotted the ST-elevation in leads aVL, aVR, and V1 (in red) accompanied by otherwise global ST-depression (in blue). This is suggestive of severe 3-vessel disease or even Left Main Coronary Artery occlusion! However, given we have a tachycardia present, we need to consider our differentials:

  • Acute onset of AF with RVR: ECG changes suggestive of demand ischemia with concomitant coronary artery disease
  • Chronic AF exacerbation: ECG changes suggestive of evolving myocardial infarction
  • Digitalis toxicity: "scooped" ST segments

While digoxin is a common drug taken by patients with chronic atrial fibrillation, digitalis toxicity is most often accompanied by bradycardia and AV-blocks. Junctional tachycardia is another common finding. A rare and bizarre finding was covered recently on Dr. Smith's ECG Blog: bidirectional ventricular tachycardia. However, digitalis toxicity is not known to cause ST-elevation in aVR and V1, and so it does not fit our clinical picture.

At this point, the paramedics were left to choose between acute paroxysmal AF and chronic AF. They elected to transport the patient to a PCI-capable center and treated the patient enroute with an IV fluid bolus and nitroglycerin for the chest pain. They contacted medical control for orders and were asked to monitor the patient as long as he remained stable.

Without knowing the patient's prior history of atrial fibrillation it is difficult to suggest a specific method of treatment in the field, especially while the patient remains stable. Paroxysmal atrial fibrillation responds well to cardioversion or calcium channel blockers. Whereas chronic atrial fibrillation often requires a correction of the underlying problem. Regardless, preparations should be made for cardioversion should the patient's condition worsen.

Upon arrival at the ED the patient's records were found, along with prior ECG's, which showed no history of atrial fibrillation but an extensive cardiac history including CAD.

During his initial assessment in the ED the patient became hypotensive and was cardioverted at 100 J with a return of a normal sinus rhythm and adequate blood pressure. Troponin levels remained below 0.4 ng/mL.

The patient remained stable through observation and was discharged home with a diagnosis of acute paroxysmal atrial fibrillation.

Posted by on September 9, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

88 year old male CC: Chest pain

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EMS is called to the residence of a 88 year old male patient with a chief complaint of chest pain.

On arrival the patient is found standing at the front door. He appears anxious and acutely ill.

Skin is pink and warm but diaphoretic.

The patient is led to a kitchen chair and the assessment begins.

Past medical history: Hypothyroidism, Dyslipidemia

Medications: Synthroid, Lipitor

History of present illness:

The patient states that he was cleaning the house when symptoms began.

  • Onset: Sudden and getting worse over time
  • Provoke: Nothing make the pain better or worse
  • Quality: Sharp
  • Radiate: Pain radiates to the left arm
  • Severity: 10/10
  • Time: No previous episodes

Breath sounds are clear bilaterally.

No JVD or pitting edema noted.

Vital signs are assessed.

  • RR: 20
  • Pulse: 68
  • NIBP: 145/85
  • SpO2: 96 on RA

The patient admits to nausea but has not vomited. He denies palpitations.

The cardiac monitor is attached and a 12-lead ECG is obtained.

Computerized measurements:

  • HR: 66
  • PR: 292
  • QRS: 146
  • QT/QTc: 414/434
  • P-QRS-T: 21, -50, -19

What is your interpretation of this 12-lead ECG?

What do you think is going on with this patient?

Posted by on September 7, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

81 year old female CC: Chest Pain

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Here is a great case from NYC Medic, hopefully you'll enjoy it as much as we did!

It's a hot summer's night in the city when the tones drop to Assist Police reference a 10-34 (assault in progress) at a large apartment complex. You arrive and find two cruisers parked, with no officers in sight. A quick check with dispatch reveals they're on the 11th floor in room 1108.

A sign on the elevator politely informs you that it has seen better days and you'll need to use the stairs.

As you exit the stairwell onto the floor you have a good idea as to the location of the scene. Shouting is audible down the hall where an officer stands outside the doorway with his arms across his chest. He motions you inside, letting you know, "they don't speak English, we think it's Russian."

An officer inside gives you a quick report, "we think he wants her to go to the hospital, but she does not want to. We haven't been able to get them to calm down."

Inside you see a large man yelling at the officer and his wife, gesticulating wildly. The wife is seated in a chair and is yelling back, their conversation unintelligible. After exchanging glances with your partner, you yell the only Russian you know, "ROSE-DEST-VOM KHRIS-TO-VIM!" (Merry Christmas!) 

The couple stops, turns to you and begins laughing. You introduce yourself and walk towards the wife, who upon closer inspection is clutching her chest. You point to her chest and ask her if it hurts; she nods her head.

Your partner spies a bag of medications on a counter and begins going through it. You place your hand on her wrist to get a pulse while he reads off the medications: "Lasix, digoxin, simvastatin, some vitamins, and coumadin."

One of the officers places her on the monitor while you get a blood pressure.

  • Skin: cool, dry
  • HR: 40, regular and weak
  • BP: 142/64
  • RR: 20, unlabored
  • SaO2: 92% on room air

The first 3-Lead print is handed to you:

Your partner ask one of the officers to go get the stair chair from your unit.

A 12-Lead is acquired:

  • Rate: 39
  • RR: 1538 ms
  • PR: *
  • QRSd: 160 ms
  • QT: 571 ms
  • QTc: 460 ms
  • P/QRS/T Axis: * / -82 / 91

What do you think is going on?

Given the patient's medications, what medical history do you think she has?

What treatments should the patient receive and should they be started in the apartment or enroute?

Posted by on September 5, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , ,

68 year old male CC: Chest Pain

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Here is a great case submitted by a faithful reader who wishes to remain anonymous. As usual, details have been altered to ensure patient and provider confidentiality.

Hurricane Irene has kept your night shift wet, windy, and you've bounced from one stranded motorist call to another. Dispatch chimes in and puts you out on a chest pain call, 68 year old male at a convenience store, no other information.

You arrive to a neighborhood grocery store and see a small crowd in the doorway. An older gentleman is seated on the ground, in no apparent distress.

You introduce yourself and ask what is going on while your partner acquires vitals.

  • Onset: 45 minutes ago he awoke with some chest pain, but went to the store anyways for supplies
  • Provocation: nothing makes the pain better or worse
  • Quality: "it's like somebody keeps punching my chest"
  • Radiation: he localizes the pain to the left side of his chest
  • Severity: increased to an 8 of 10, "sometimes I can't catch my breath"
  • Timing: constant

Your partner turns and gives you his vitals:

  • Skin: cool, dry
  • HR: 130, irregular but strong radials
  • RR: 26, yet unlabored, too windy to hear lung sounds
  • BP: 138/86
  • SpO2: 95% on room air
  • Temp: 36.9 °C
  • BGL: 195 mg/dL (10.8 mmol/L)

Your patient reports a general "cardiac" history and is unable to remember what medications he is on, stating only that they, "are numerous."

With some help from the bystanders you assist the patient to your stretcher and move him to your unit to get out of the elements. Your partner places him on the cardiac monitor while you place him on a nasal cannula and listen to his lung sounds.

You note that his lung sounds are clear and equal bilaterally as your partner hands you the initial 3-Lead. Your patient denies any history of arrhythmias and says at his last checkup he was, "healthy as a horse."

A 12-Lead ECG is acquired.

With Irene still pummeling the Eastern seaboard, it will be at least a 20 minute ride to the closest facility, 30 minutes to the closest PCI capable center. Your partner asks if you'd like him to request a driver.

What is your patient's rhythm and what treatments should your patient receive?

What does the 12-Lead ECG show?

Does the patient need a PCI capable facility, why or why not?

Posted by on September 4, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , ,

46 Year Old Female: Injuries From a Fall- Discussion

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This is the discussion for 46 year old female: injuries from a fall. You may wish to go back and review the case.

To begin with, lets review the patient presentation.  Is there anything based on presentation that raises red flags for Acute Coronary Syndrome (ACS)?

She is pale and diaphoretic, with nausea and vomiting. She also complains of feeling "weak".  Diaphoresis alone is one of the most concerning signs of ACS; and of course, there is the bilateral shoulder and arm pain.  Considering the diabetic history, I think we all would be suspicious of ACS in this patient.

However, there is the matter of the fall the night before. The shoulder and arm pain, and other symptoms, could be attributed to the fall.

One of the biggest challenges we face is assessing for ACS in the presence of other injury of disease, which can distract us from serious signs and symptoms. Can we imagine a scenario where medics attribute the patients complaints to the fall, and don't even run a 12-lead? I think we all could see how that could happen.

Another confounding factor is the high blood glucose.  In this case however, the paramedic, who by his own admission was not initially thinking ACS, registered enough red flags that he rightly investigated ACS.

Now, let's look at one of the 12-leads:

The rhythm is sinus bradycardia, with a first degree AV block.  That happens often with an inferior wall MI, and I'm sure many of you were looking to the inferior leads. As most commenters pointed out as well, we see ST elevation inferiorly, with reciprocal depression in leads I and aVL.

What about concurrent Right Ventricular Infarction (RVI)?

What ECG signs do we look for to determine if an RVI is present? Let's review:

  • IWMI
  • ST elevation in III > II
  • ST elevation in V1

We have IWMI… if we compare leads II and III, we see that indeed the ST elevation in III > II:

If we look at V1, we see there is about 1 mm of ST elevation there as well:

It is also reasonable to get a right sided V4R, to look for ST elevation.  The paramedic did that in this case, and this is what it showed:

In the presence of IWMI, any ST elevation > 0.5mm in V4R should be interpreted as RV MI.

Regarding the patient presentation, the hallmarks of RVI are:

  • Hypotension
  • Clear lung sounds
  • JVD

Now, how about treatment for suspected RVI? In this case, the crew could not gain IV access.  ASA was given, but NTG was held off due to the low BP and no IV access.  Fluids would have been indicated.  

NTG and Inferior Wall MI's seems to be a frequent topic of debate. Can we give NTG in the presence of RVI? We are all familiar with the anecdotal bottoming of pressure due to giving NTG, but while it may happen, it is not the rule.  If the patient's BP is normotensive, can we give it?

Do we give it "cautiously", whatever that means (I always picture taking great care while squeezing the nozzle on the NTG spray)? While i think we all would agree that it is contraindicated in the presence of hypotension, there is not uniform agreement if the pressure is normotensive, of hypertensive.  

What do you think?

The crew took this patient to the nearest PCI center, where she was rushed to cath and found to have a 99% blockage.  While the culprit artery was unknown to the crew, however, it would be fair to speculate that the RCA was occluded.  She received stents, and was discharged several days later and was expected to make a full recovery.

Posted by on September 1, 2011 • Filed under: ems-health-safety, ems-topics, patient-management • Tagged: , , , , ,