Module #3

Contrast left and right-sided infarcts in relation to indications and contraindications of fluid boluses
and nitroglycerin.

Left-sided Acute
Myocardial Infarctions
Pathophysiology

*Damage to the left ventricle

compromises the hearts ability to
send oxygen rich blood to the
rest of the body.
*The drop in cardiac output
stimulates compensation, which
results in tachycardia and
increased BP from circulating
catecholamines.
*Dyspnea results from pulmonary
congestion, as the injured left
ventricle is unable to eject its
contents and blood flowing in
from the lungs has no where to
go.

Symptoms

*Tachycardia, hypertension,
dyspnea
*Typically patients have a 3rd or
4th heart sound and may develop
mitral regurgitation.

ECG

*Stretch in the atria from

congestive failure may develop
afib, a flutter or SVT.
*Damage to the His-purjinke
system can give rise to a new
onset BBB , a sign that reflects
the loss of left ventricular
myocardium.

Special Considerations
Nursing Interventions

Fluids

*Assess patient and get an ECG

stat
*Administer supplemental O2
*Implement continuous cardiac
monitoring
*Start an IV
*Draw blood for CBC, Lytes,
Cardiac enzymes, PTT, PT-INR,
MG, Baseline lipid profile
*Fluid restriction

Medications

*Give 325mg aspirin

Mainstay of treatment is
nitroglycerin (if systolic BP is
greater than 90 mm Hg) and/ or
*Morphine to reduce preload and
manage pain

Rationale

*Intervention is aimed at
reducing myocardium workload,
managing pain, and minimizing
the risk of pulmonary edema.
*Fluid restriction and diuretics are
given to control pulmonary
congestion.

Right-sided Acute
Myocardial Infarctions
*The heart begins to loose its
ability to handle systemic venous
return therefore the right atrial
pressure rises and jugular vein
distention occurs without
pulmonary congestion.
*When the compromised right
ventricle cannot eject its
contents, cardiac output drops,
leaving the left ventricle in a
state of hypovolemia.

*Hypotension, bradycardia,
nausea, vomiting, hiccoughing,
the urge to defecate as the result
of parasympathetic stimulation
from increased vagal tone.
*The classic triad of distended
neck veins, clear lungs, and
hypotension is a sign of acute
right MI.
*Suspect R acute MI if pt presents
with an inferior wall MI.
*Ischemia of the SA or AV nodes
or bundle of His can also cause
bradycardia or 1st 2nd or 3rd
degree heart block.

*Place cardiac monitor leads in

the right chest can help to
identify ST elevation.
*Assess patient and get and ECG
stat
*Administer supplemental O2
*Implement continuous cardiac
monitoring
*Start an IV
*Draw blood for CBC, Lytes,
Cardiac enzymes, PTT, PT-INR,
MG, Baseline lipid profile
*Treatment involves aggressive
fluid resuscitation, which may
include infusing 1-2 L NS bolus
over a short period of time.
*Give 325mg aspirin
*If fluids do not correct the failure
doputamine may be used to
enhance contractility, reduce
afterload and increase flow of
blood to boost the cardiac output.
*Preload reducing agents such as
morphine, diuretics, and nitrates
should be avoided.
*The purpose of the fluid bolus is
to raise the preload and right
ventricle filling pressure and to
maximize the contractility and
blood flow from the right
ventricle to the left.

References
Almeda, F. Q., Snell, R. J., & Parillo, J. E. (2001). The contemporary management of acute myocardial infarction.
Crit Care Clin, 17(2), 411.
Coven, D., & Pershad, A. "Right ventricular infarction." 2002. www.emedicine.com/med/topic2039.htm (1 Feb.
2002).
Closchesy, J., Breu, C., et al. (1996). Critical care nursing (2nd ed.). Philadelphia: W. B. Saunders.
Horgan, L. G., & Flowers, N. C. (1999). Right ventricular infarction: Specific requirements of management. Am
Fam Physician, 60(6),1727.
Goldberger, A. L. "Electrocardiogram in myocardial ischemia and infarction." UpToDate Online 10.1. 2001.
www.uptodate.com/html/prcard.htm (1 Feb. 2002).
Lynn-McHale, D. J., & Carlson, K. K. (2001). AACN procedure manual for critical care (4th ed.). Philadelphia: W.
B. Saunders.
Bucher, L. (1999). Acute myocardial infarction. In L. Bucher & S. Melander (Eds.), Critical care nursing (1st ed.),
(pp. 227 257). Philadelphia: W. B. Saunders.