NREMT Paramedic Cognitive ExamCardiology & ResuscitationHard
A 60-year-old male presents with acute onset of severe substernal chest pain that began 30 minutes ago. He is pale, diaphoretic, and states he feels 'terrible'. His vital signs are BP 88/50 mmHg, HR 50 bpm, RR 18 bpm, SpO2 94% on room air. The 12-lead ECG shows ST-segment elevation in leads II, III, and aVF. Which of the following medications is CONTRAINDICATED in this patient?
- ANitroglycerin 0.4 mg sublingually.
- BFentanyl 50 mcg IV.
- COxygen via nasal cannula.
- DAspirin 325 mg orally.
Show answer & explanationAnswer & explanation
Correct answer: A. Nitroglycerin 0.4 mg sublingually.
The patient has an inferior wall STEMI (ST elevation in II, III, aVF) presenting with bradycardia and hypotension. Nitroglycerin, a vasodilator, would further decrease blood pressure and potentially worsen his condition, making it contraindicated. Inferior MIs often involve the right ventricle and can be preload-dependent, making vasodilation dangerous.
Why the other options are wrong
- B. Fentanyl is a safe option for pain relief if nitroglycerin is contraindicated or ineffective, given its minimal hemodynamic effects compared to morphine in some cases.
- C. Oxygen is appropriate if the patient is hypoxic (SpO2 < 90%) or in respiratory distress. His SpO2 is 94%, so it's not absolutely indicated but not contraindicated.
- D. Aspirin is indicated for all STEMI patients unless contraindicated (e.g., active bleeding).
Nitroglycerin Contraindications
Nitroglycerin is a potent vasodilator used for chest pain, but it is contraindicated in certain cardiac conditions due to its effect on blood pressure and preload.
- Contraindicated with SBP < 90 mmHg.
- Contraindicated with recent PDE5 inhibitor use (e.g., sildenafil, tadalafil).
- Use with caution in inferior MI, especially with bradycardia or right ventricular involvement, due to preload dependency.
Memory trick: Inferior MI + Brady/Hypo: 'No Nitroglycerin' – it's a 'No-Go'!