46 Year Old Female: Injuries From a Fall- Discussion

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.

7 Comments

  • medic372 says:

    Personally if the patient has confirmed RVI with normotension I would not give NTG because of the pathology of a right sided MI. The patient is going to have a decreased preload to the heart and there bodies are just compensating right now. If you give NTG which will further decrease the preload there compensatory mechanism just got stopped and there BP will drop. I have never seen a RSMI with hypertension personally but I'm sure theres been plenty of cases of them, in which case, I may feel more comfortable giving the NTG.

  • Brian A says:

    In the case of a RVI nitro as given in the field is a bad thing (.4mg of nitro that we give as a single dose in the field is equal to 400mcg. In the ER patients are started on nitro drips at only 5 to 20mcg/min). Right sided failure means that any blood pressure the patient has is dependent on their preload. In an attempt to improve perfusion by giving nitro to dilate coronary artery vessels we dilate all of their vessels, seriously reducing the patient’s preload, and effectively eliminating their blood pressure. Being unable to obtain IV access in this scenario doesn’t help either. Consider using the presence of JVD to your advantage and start an external jugular IV and start pushing the fluids. The pt is only 46 years old so even a 1000cc bolus would be ok. In the presence of severe pain associated with her MI I would give 50 to 100mcg of Fentanyl and avoid any nitro or morphine.

  • Troy says:

    Nitro is a class III treatment with RVI…..not a IIb or IIa. That, according to AHA, is shown to be more harmful than beneficial. Why do we give nitro anyways??? To vasodilate the artery and try to limit the ischemic pain. Why not just give fentanyl?

  • Bruce Sutton says:

    morphine would benefit the heart better than fentyl no proven documentation that fentyl helps profuse the heart in this instance we would want to tank them up, fluid would benefit greatly.

  • Matt says:

    Bruce – I would be concerned about the vaso-dilatory effects of morphine in the presence of RVMI with an SBP already in the 90's. I would have to agree with other posters and say Fent would probably be a better option here if we're going to give narcotic analgesia.

  • Christopher says:

    Bruce,
    Unfortunately, Morphine has not been proven to benefit during AMI and a few studies have even shown it is harmful during AMI. Fentanyl has not been shown to be harmful during AMI and can work to aleviate some of the pain.
    That being said, yes to fluids!

  • saraswathi thangavel says:

    excellent.. thanks
     

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