The other day I had a case that raised my BP. Ultimately, it worked out well but not before I felt the need to do some deep breathing exercises. So, this obese 55 year old guy drives himself in during a busy-ish period for chest pain at rest an hour ago. Even before he got his EKG, the charge nurse came over to the doctors area and said “one of you guys has to go see 13, he looks like total shit”. I volunteered to go (since my colleague is recovering from an injury and was anxious about the guy’s bulk and the possibility of having to move him or something). Anyway, he did indeed figuratively look like crap. He talked easy enough and even said his pain was nearly gone – but his drenched-in-sweat appearance, pallorous hue, and the 77/39 on the cardiac monitor told me otherwise. The EKG was handed to me hot off the press and it showed…… nothing much. What a disappointment. I was expecting either a STEMI, third degree heart block, or something dramatic. Nope, just nonspecific ST changes with a HR of 52. Quickly finding an old one of his showed it was the unchanged in the last 4 years. Hmmmmm. Well, I ordered a litre fluid bolus and the standard cardiac labs, etc. I went back to chart. Then 5-10 min later, the nurse grabbed me to tell that despite getting most of that litre into him, his SBP was 59! His HR was now 42 (but still in sinus)! Great, now he is going down the toilet and I don’t know why. I spoke to him again and basically, he said except for some mild nausea and sweating, he felt OK. No pain anywhere. No previous back pain, abdominal pain or head ache. His exam was unexciting except for his appearance and vitals. CXR was normal. BTW, his pulse ox was normal too (despite his sheepish admission that he smokes a pack a day). Well, I guess I have to start something. I opted for Dopamine for its BP and HR support. Starting at 10 mics, his BP started coming up, as did his pulse rate. Again, I went back to chart and wait for some labs to come back. 5 minutes later, the RN again grabs me (literally this time) to tell me his is having terrible chest pain. His HR was now 100 and his SBP was 125 (better numbers but now he again looked terrible). “Doc! My chest is KILLING me!”. OK, turn off the Dopa and repeat the EKG. Hmmm, no machine or EKG tech around – so I better go get it myself……. Luckily a tech came over with the machine just as I was getting sweaty myself and ran it again. NOW, I have an answer. Tombstones in the inferior leads. Ah ha! Call the cath team in and the interventionalist, give the Aspirin and Clopidogrel. But else what to give him now? I don’t want him to be back with a BP of 70 and bradycardic. More fluids, more fluids, more fluids and get some atropine ready if he gets bradycardic again. See, turns out he was also having a Right ventricular infarction. That is is what made him hypotensive while the Left ventricular inferior wall infart made him bradycardic. I was about to start nitro on him for his pain but luckily turning off the Dopa made his pain much better in about 3 minutes. The cardiologist came in and took him to the cath lab where he had a 99% occlusion of his prox RCA and did OK with a stent- I guess it was opening and closing which is why his pain suddenly shot up when we spanked his heart with that Dopamine but then got better when we stopped it. Turns out, another good drug choice for his particular situation is good ole’ Aminophylline (which no one uses even for asthma anymore). Next time…..
Lesson to learn: RV infarctions look like shit and need a crap-load of fluids.
Great case. Funny — your lede was “raised my blood pressure,” and seeing that ECG I thought it was a neat play on words for the patient whose blood pressure was in the crapper.
RV infarctions are scary — good thing you didn’t turn on the nitro — Rv infarctions are really preload dependent and that would have dropped his blood pressure way way more.
I kind of like inferiors because patients look so *sick* it’s really gratifying to find the Dx and fix ‘em.
Yeah, I was dreading having to start the nitro. If I did, I was going to start it at like 10- 20 mics and restart the Dopamine to support the BP if needed. Glad I didn’t have to go there….
Turns out he is now doing crappy up in the CCU in heart failure and heart block.
I’m always glad when I put the defib pads on those pts too….had v-tach to many times to forget
I had a case exactly like that. Nothing except bradycardia on EKG, hypotensive….started dopamine and out came the tombstones.
Good thing you had good nurses who kept you updated on your patient!
I do recovery room for OB related OR cases on L&D. So, needless to say, I don’t see abnormal EKG strips too often. Reading 12 leads? Totally not my groove. However, that 12 lead up above: I can definitely see prolonged QRS complexes. (I’m looking at V5) — absence of P waves, elevated T waves. Are the prolonged QRS complexes the “tombstones” that you’re referring to? As for the rest of the leads….totally lost on how to interpret them. Once again…..I’m only trained on simple 3 leads for the PACU.
Leads II, III, and avF have a “tombstone” appearance to the S-T segments….
RVI is usually memorable. Almost the opposite of the rest of the STEMIs. Dump fluid into them until you think they can tolerate some NTG, then you are playing catch up, again.
I do not like giving pressors to any infarcting patient, but for RVI it is a fluid problem, not a catecholamine problem. Outside of the hospital the downside of pressors in RVI is too great. Anything with ST elevation in II, III, and aVF should be assumed to be RVI until proven otherwise. It is too easy to kill RVI patients.
Nice job and your nurse, too.