STEMI – V4R to the rescue – IWMI – RVMI – PWMI

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November 15th, 2009 by RH-111

Doing rotations on 27v out of Montefiore and had this patient:

69 yea old female – chest pain x 7 hours started after grandson was taken in by EMS due to a febrile seizure. Pt has history of multiple stents placed a few years ago out of the country, no follow up care since then. Pt takes a statin and a beta blocker for HTN. Pt describes a substernal dull pain 8/10 radiating down left arm. Vitals are HR 84, BP 122/100, RR 24, Spo2 99% on room air, lungs C&E Bilat. ECG is NSR without ectopy. 12 Lead ECG obtained with our Lifepak 12 reveals ST Elevations in Leads II, III, aVf, V1-V4, poor R wave progression and a curious rsR pattern in V1, width of 89ms. Reciprocal changes noted in Lead I and aVl. After ascertaining that there were no allergies pt was given 162mg of chewable ASA and placed on 3lpm via Nasal cannula.

Prior to administration of NTG a V4r lead was obtained which revealed ST elevations of 1mm. IV placed, 18ga Left A/C and 250cc fluid bolus administered. NTG admin 0.4m SL which offered minimal relief. B/P now 110/p – NTG repeated 0.4mg SL, this time patient offers that her pain is now 5/10. Repeat B/P is 102/64. Normal Saline left running wide open.

At this point we are at the ED, a STEMI alert had been called. 12 Lead in ED confirms the same and cardiologist calls it positively based on the V4r obtained in the field. NTG repeated in the ED causes BP to fall to 84 systolic, squeezing the bag and another 250 cc of NS gets her back up to 94 systolic.

Pt is transported to the cath lab on our stretcher and my preceptor is kind enough to allow me to stay and watch the case. LAD and LCx both freely flowing. RCA – 100% proximal occlusion.

I’ll be getting a v4r on every IWMI before NTG.