November 4, 2024

“To Nitro or Not to Nitro” 

“911, what is your emergency?” 

“My husband is pale and sweaty; he is clutching his chest” 

“Is he breathing appropriately?” 

“Yes, he is breathing normally but looks very uncomfortable.” 

“Ambulance is on the way.” 

On arrival, you find a 65-year-old male with a history of hypertension and hypercholesterolemia clutching his chest. He reports this came on suddenly while tinkering on his ‘65 Ford Mustang. 

Vitals: 100/70, p=100, r=20; he is sweaty and reports it feels like an elephant is sitting on his chest. 

EKG: 

EKG is rapidly sent to the receiving ED and you report he is not on blood thinners, no ED medication, no platelet inhibitors. None of this pain is going into his back and there is no tearing sensation. 

You have already given 4000 Units of Heparin IV and 180 mg of Brilinta orally. His wife gave him an adult aspirin that he chewed up before EMS arrived. His pain is 10/10. 

Treatment? 

Fentanyl is a great choice for pain rated as 10/10, it is short-acting, and severe pain increases the demands on an already compromised heart. However, anyone with pain rated as equal or less than 7/10 should not be given a narcotic, as this will decrease his oral medication absorption that he critically needs for his stent placement. Stents usually fail immediately and appropriate anti-platelet and anticoagulant therapy is critical. 

Nitro, although part of your chest pain protocol, should also be avoided. Remember that the inferior wall myocardial infarction (MI) is a right ventricle MI and this is the start of the entire preload of the heart. These are the patients that can become profoundly hypotensive when given nitro. Many of you may have used nitro with MI patients and you can frequently get away with it, however, with the inferior wall MI patient, it should be avoided. 

Nitro discussion

Nitro has many uses and finds beneficial effects with heart failure. Although it does not improve mortality in our MI patients, it does help with those patients suffering from pulmonary edema. It can also improve pain when used outside of the inferior wall patient who has a systolic that is higher than 90. Other cautions or contraindications include: 

1. Systolic less than 90. 

2. Hypertrophic cardiomyopathy: this may cause outflow tract obstruction by volume decrease. 

3. Aortic stenosis: adding nitro here can also cause a profound drop in blood pressure. 

4. Erectile dysfunction medication: may have severe drops in blood pressure with nitro. 

5. Pulmonary hypertensive medication: may have severe drops in blood pressure with nitro, like the ED medications. 

6. Tachyarrhythmia: Fix the rate first and decrease the oxygen demand. 

7. Heart blocks: Treat the rate first. 

8. Inferior wall MIs. 

When in doubt, call. This includes if you are not sure whether the EKG is a STEMI or not. We know how frequently the computer on the machine is wrong. Trust your reading and try not to be swayed by the computer reading. I never look at the computer reading until I have completely read the EKG. 

The patient arrives at the ED and your team is directed directly to the Cath lab. Time is muscle and your excellent focus on time and patient care gets this fortunate patient revascularized in record time. Well done! 

Don Spaner, MD

November 11, 2024

Extracorporeal cardiopulmonary resuscitation (ECPR) is a program only available at UH Main Campus with special training provided to EMS departments within the central eastern ring of UH Cleveland Medical Center communities. The Cleveland Clinic Foundation (CCF) is preparing an ECPR program which will go live early in 2025. The cooperation with Dr. Frank Forde and Dr. Colin McCloskey from UH, Dr. Jacqueline Tamis-Holland from CCF, as well as the Harrington Heart and Vascular Center and CCF Cardiology Department, have brought these amazing programs to life in our area. 

The future for these critically ill patients is becoming more hopeful. These exciting programs give second chances at life to those between the ages of 18-70 with an initial shockable rhythm. We have always asked our paramedics to stay and play, as it is a well-known fact that if the return of spontaneous circulation is not attained before entering the ambulance, the odds of a patient surviving to discharge are dismal. With ECPR, we ask our well-trained providers to capture a shockable patient, defibrillate them, and move them with standard Advanced Cardiac Life Support care and outstanding CPR, to an ECPR center as rapidly as possible. The UH ECPR program already has patients who have survived to discharge. The process involves cannulation of the femoral vein and artery, and the use of extracorporeal membrane oxygenation (ECMO), which has been used for years in cardiogenic shock patients, whose hearts can no longer properly perfuse the patients. They provide adequate oxygenation while the heart recovers and undergoes the appropriate repairs. The following is the proposed regional protocol for ECPR.  

Inclusion criteria: 

1. Approximate age 18-70 years. 

2. Witnessed arrest. 

3. Initial rhythm VF/VT. 

4. Expected transport time <30 minutes. 

5. Able to provide mechanical CPR. 

6. ETCO2 >10. 

Exclusion criteria: 

1. Clear advanced directives with DNR status. 

2. Long-term care facility/nursing home. 

3. Known terminal illness. 

*When identifying a candidate for ECPR, notification of the ECPR center is extremely critical. The ECPR center will also require a lactate &lt;15, a PH &gt;7, and CO2&gt;20.

There will be more to come and discuss with ECPR as the program grows and more lives are saved. Our Harrington Heart and Vascular Center team will do a live broadcast on PrehospitalParadigm.com on Monday, November 25th at 7:00 pm from the University Heights Fire Department. Please join us for a great evening of education. University Heights FD was the first department that also worked with Cleveland Heights FD to successfully deploy their critical new skills and allow a cardiac arrest ECPR patient to walk out of UH CMC. 

Thanks for everything that every one of you does, saving lives and bringing cutting-edge technology to all our family and friends.   

Don Spaner, MD

November 18, 2024

We know many contraindications for platelet inhibitors and anticoagulants during myocardial infarction (MI). The obvious are bleeding issues, recent major surgery, allergies to the medications, and already being on the specific class of medications. Still, there is also a STEMI situation in which these medications are contraindicated. We recommend holding Aspirin, Brilinta, and Heparin if your STEMI patient has tearing, sudden onset chest pain radiating between the scapulas. This can be related to an aortic ascending dissection. The right and left main coronary arteries originate from the base of the ascending aorta. Suppose the ascending aorta suddenly dissects and damages one or both coronary arteries. In that case, the provider will see a STEMI on the EKG and assume this is a typical plaque rupture STEMI. Unfortunately, this will cause the provider to utilize this prep medication for emergency catheterization medications. This would be a very dangerous decision and could significantly harm a patient who may already have a high mortality event. The pre-hospital decision-making can be enhanced with some very rapid clinical evaluations. 

Suspected Ascending Aortic Dissections, with or without STEMI

1. Sudden tearing chest pain. 

2. Radiation of pain straight to the back. 

3. Blood pressure differences between arms. A difference of >20 is very concerning. 

4. Pulse differences between arms. 

5. Paresthesia on one arm with chest pain. 

6. Cool arm with chest pain.  

Any one of these is enough to withhold aspirin, Brilinta, or Heparin. Here, the ED doctor will complete a rapid chest X-ray, bedside ultrasound, and CT angiogram of the chest, before considering using these medications. We will also notify the interventional team to assist us with caring for this patient, who can then go to the Cath lab once this is ruled out. If the ascending aortic dissection is confirmed, this is a type A dissection and cardiothoracic surgery will need to be involved with an emergency surgery. 

Remember: sudden tearing chest pain, especially with back pain, at a minimum, needs blood pressure readings in both arms. If the story or clinical findings are concerning for a dissection, the use of anti-platelet or anticoagulant medication should be held. The other critical point is that the great vessels must be involved to see the B/P differences; not having a difference in B/P between arms does not rule out a dissection. So, the sudden tearing chest pain radiating to the back is enough to hold these meds. 

Thanks for spending the time to review pre-hospital care for the ascending aortic dissection. 

Sincerely, 

Don Spaner, MD

November 25, 2024

Thanks for joining me for my last Monday Morning Medical Director’s Message. Today’s question is: Does your patient demonstrate cardiogenic shock?  

Your patient is a 75-year-old female who is lightheaded and feels like she is going to pass out. She is on Entresto and Lasix and has been very compliant with her medication. However, she has been getting weaker, and over the last day, she can’t walk without near syncope. She noticed her urine was very dark and hadn't produced much over the last 24 hours. She appears fluid overloaded with bilateral leg edema, jugular venous distension, and rales noted on her lung sounds. Her vitals are B/P= 80/60, P=120, POX=90%, RR=24 BPM. She appears weak and ill. She denies dysuria, no infected wounds, no abdominal pain, and no cough. She has not been bleeding, has no melena, no rashes, and denies fever or chills.  

You believe she is in cardiogenic shock, perhaps because you apply the C.O.L.D. pneumonic (see below). Her B/P is low. She is not producing much urine, and it is dark, which may indicate renal failure and liver damage. She is volume overload, so additional fluids may be harmful. You decide to mix 1 mg of epinephrine 1 mg/1 cc to 100 cc of D5W and you administer push dose epinephrine to maintain a MAP of 65. You remember that cardiologists are moving towards cardiac mechanical support. This will allow the heart to rest and either recover or sustain the patient for further mechanical or transplant care. Outstanding care by the pre-hospital team alerts the ED as they notify our heart failure team and prepare for emergent mechanical support. Well done! 

This is an exciting time in which decades of chemical pressor support are being minimized and transitioning to cardiac mechanical support, myocardial rest, and recovery. Thank you to all involved with this exciting time of cardiac second chances. During this Thanksgiving, I hope all of you, who give so much, can find time to enjoy your family and friends. Happy Thanksgiving to all. 

Don Spaner, MD