Cardiac Ischemia | SWORBHP Ask MAC

Category Archives: Cardiac Ischemia

September 25, 2012 SWORBHP Category: Cardiac Ischemia | Date: 25-Sep-2012

Question: What are your thoughts on CPR with ventilations vs. continuous chest compression CPR? - Student PCP

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Answer: Great question! As you know, CPR is not a delegated act, and Base Hospitals are not tasked with medical oversight of chest compressions. Therefore, while we may have varying opinions as to CPR methods, since this is a BLS skill, paramedics are mandated to follow the current guidelines from the Heart and Stroke Foundation of Ontario (HSFO). These guidelines are included in the booklets we provide for certified paramedics within the Southwest region. HSFO Guidelines are usually based upon the American Heart Association Guidelines last released in 2010.

A link to the entire guidelines can be found here:
http://circ.ahajournals.org/content/122/18_suppl_3.toc

Specifically for CPR, the overview in Part 4 can be found here:
http://circ.ahajournals.org/content/122/18_suppl_3/S676.full.pdf:

In Part 4: CPR Overview (Travers et al 2010) page S677, the guidelines state: “Chest compressions are the foundation of CPR. All rescuers, regardless of training, should provide chest compressions to all cardiac arrest victims. Because of their importance, chest compressions should be the initial CPR action for all victims regardless of age. Rescuers who are able should add ventilations to chest compressions. Highly trained rescuers working together should coordinate their care and perform chest compressions as well as ventilations in a team-based approach”.

Specifically relating to compression only CPR, the authors support a phased strategy depending upon the level and training of the provider. They go on to state: “Opening the airway (with a head tilt– chin lift or jaw thrust) followed by rescue breaths can improve oxygenation and ventilation. However, these maneuvers can be technically challenging and require interruptions of chest compressions, particularly for a lone rescuer who has not been trained. Thus, the untrained rescuer will provide Hands-Only (compression-only) CPR (ie, compressions without ventilations), and the lone rescuer who is able should open the airway and give rescue breaths with chest compressions. Ventilations should be provided if the victim has a high likelihood of an asphyxial cause of the arrest (eg, infant, child, or drowning victim). Once an advanced airway is in place, healthcare providers will deliver ventilations at a regular rate 1 breath every 6 to 8 seconds (8 to 10 breaths/minute) and chest compressions can be delivered without interruption.”

Since the publication of these guidelines in 2010, more literature has been published looking at the role of compression only CPR and it is possible that these guidelines when revised in 2015 may look different…who knows!

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Cardiac Ischemia

July 3, 2012 SWORBHP Category: Acute Cardiogenic Pulmonary Edema, Cardiac Ischemia | Date: 03-Jul-2012

Question: Do all Phosphodiesterase Inhibitors generic names end in "fil"? Are all drugs that end "fil" Phosphodiesterase Inhibitors? Is this an adequate way to start down the path toward withholding Nitro due to Phosphodiesterase Inhibitor contraindication?

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March 28, 2012 SWORBHP Category: Cardiac Ischemia | Date: 28-Mar-2012

Question: In the previous cardiac ischemia medical directive it said that if the patients symptoms resolved after the administration of nitro and then returned that you could administer another 6 sprays of nitro. I was wondering if this was still the case.

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Cardiac Ischemia

March 28, 2012 SWORBHP Category: Cardiac Ischemia, Return of Spontaneous Circulation | Date: 28-Mar-2012

Question: I have a few questions about some of the omissions from these protocols that were in the old protocols. The first one is in the event chest pain resolves and re-occurs it is treated as a new episode and nitro protocol repeated. This isn't stated in the new protocol so if this were to occur can we repeat although it isn't stated? The other question is regarding the medical arrest protocol. No provision is made in regards to on scene ROSC and re-arresting patient in ambulance. The old protocol says we can pull over and analyze once then continue to receiving facility. With nothing in the new protocol do we follow the same format? Thank you.

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March 1, 2012 SWORBHP Category: Cardiac Ischemia | Date: 1-Mar-2012

Question: When is a patient no longer considered nitro naive? Issue: you have a patient that is suffering chest pain and qualifies for ischemic protocol. You establish a patient IV and give them nitro. The patient accepts the nitro without any adverse reactions and pressure does not fall out of protocol at any time. After your second dose of nitro you check the IV and discover it’s no longer patent and you have to discontinue it. You attempt your second IV and are unsuccessful. Nitro has been decreasing patient's pain but they still have active chest pain. Can we still continue with nitro without an IV as the patient has already been given nitro and not had any reaction?

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Cardiac Ischemia

February 6, 2012 SWORBHP Category: Cardiac Ischemia | Date: 6-Feb-2012

Question: If a patient presents with both chest pain and sudden onset stroke symptoms, can we still give all medications for cardiac ischemia protocol while doing stroke bypass?

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Cardiac Ischemia

January 31, 2012 SWORBHP Category: Cardiac Ischemia | Date: 31-Jan-2012

Question: Can you clarify a condition in the contraindications for nitro use protocols? Current contraindications listed under the protocol are self explanatory, where as one to me seems to be very vague. The one I’m referring to is the use of a "Phosphodiesterase Inhibitors" within the previous 48 hours. They are many examples of this type of inhibitor (including caffeine) and it might reduce confusion if the specific and relevant ones were listed under the protocol specific to cardiac. For example, a patient who has had a cup of coffee prior to your arrival or 48 hours prior to for that matter has ingested a Phosphodiesterase Inhibitor. Under the current directive and the way it is written, could be argued that this patient is contraindicated to receive Nitro.

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Cardiac Ischemia

January 31, 2012 SWORBHP Category: Cardiac Ischemia | Date: 31-Jan-2012

Question: When treating a patient with suspected cardiac ischemia, should I acquire a 12-Lead ECG before giving nitro or ASA? If the patient is hypotensive, should I bolus at 20 ml/kg, or 10 ml/kg as per the cardiogenic shock directive? And how do I know if the patient has a right ventricular infarct? (Updated)

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Answer:

Paramedics should work as a team on scene. Ideally, obtaining incident history, applying the monitor and acquiring a 12-Lead ECG, assessing for indications and contra-indications for ASA and NTG should be performed in concert by a paramedic crew. The Medical Directors of SWORBHP do not wish to be so prescriptive as to dictate on scene which procedures if indicated are performed first.Do not delay one for the other. If appropriate, administer NTG or ASA or perform a 12-Lead when able. Short scene times are preferred. Although ECG changes are indeed dynamic, they are not so volatile most often to be changed dramatically within seconds to a few minutes.With that said, one strategy could be to give ASA first as it decreases mortality for MI, and nitro doesn’t.

If the nitro makes them vomit then they may not keep ASA down. This strategy is only a suggestion based upon clinical experience and not a mandatory approach. The proper IV fluid bolus amount for a patient with suspected cardiac ischemia or STEMI should be 10ml/kg.A right ventricular MI is usually diagnosed by using right sided leads. Specifically, lead V4 is moved across to the right side chest to the same anatomic location. It is then called Lead V4R. If ST segment elevation is noted (classically in the setting of an inferior MI), then this is diagnostic of a Right Ventricular Infarct. It is true that a Right Ventricular Infarct would be not the ideal clinical situation to have NTG administered (that is why it is listed as a contra-indication if recognized on a 12-lead). With that said, classically Right Ventricular Infarcts are bradycardic and hypotensive.

This is exactly why the NTG directive is designed so cautiously. If a patient is bradycardic HR < 60 or hypotensive, or a patient drops their BP significantly with NTG administration (indicating pre-load sensitivity as seen in Right Ventricular Infarcts), then NTG is contra-indicated. These restrictions are designed specifically for the unrecognized Right Ventricular Infarct and herald back to a time before 12-lead ECG was widely deployed among paramedics.

*This question was updated on February 7th 2020

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Cardiac Ischemia

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