Clinical scenario
The dawn was breaking and a 46 years old gentleman presented to the ER complaining of severe chest tightness of 1-hour duration. The chest pain was retrosternal, pressure like associated with SOB and vomiting. It radiated to his left shoulder and was not relieved by rest, There was no palpitation, LL edema, orthopnea or PND. No fever, decrease LOC, seizure, abdominal pain or other pulmonary symptoms. He had been hypertensive for 5 years He had a history of an anginal attack 3 years ago No history of surgery
Examination:
The patient was conscious but tachypneic.
He was in obvious distress and had cold extremities with profuse sweating BP: 72/48. HR: 89. O2 sat: 98% on RA. RR: 19. T: 37.1 c CVS: S1 + S2+ 0, no murmur, no LL edema, no JVD Chest: equal air entry bilateral with no added sound Other clinical exams were unremarkable
Investigations
CBC: Normal,K: 4.8, Na. 138,Cl : 92,Urea: 54,Cr: 1.1 ECG: rate: 82, rhythm: regular, axis: normal, normal QRS complex, ST elevation in AVR and V1 more than one small square with ST depression in inferolateral leads as shown in Fig.1
Trop I : 488 ng ( normal range : <50 ng)
Hospital course :
Teaching message
Fill the tank in cardiogenic shock before you start vasopressors and chronotropic support.
Don’t give medication which will aggravate hypotension
Contributed by
Dr.Yasser Hussain Alnofaiey Assistant professor of Emergency Medicine, Taif University Contact Dr. Yasser: Twitter
The dawn was breaking and a 46 years old gentleman presented to the ER complaining of severe chest tightness of 1-hour duration. The chest pain was retrosternal, pressure like associated with SOB and vomiting. It radiated to his left shoulder and was not relieved by rest, There was no palpitation, LL edema, orthopnea or PND. No fever, decrease LOC, seizure, abdominal pain or other pulmonary symptoms. He had been hypertensive for 5 years He had a history of an anginal attack 3 years ago No history of surgery
Examination:
The patient was conscious but tachypneic.
He was in obvious distress and had cold extremities with profuse sweating BP: 72/48. HR: 89. O2 sat: 98% on RA. RR: 19. T: 37.1 c CVS: S1 + S2+ 0, no murmur, no LL edema, no JVD Chest: equal air entry bilateral with no added sound Other clinical exams were unremarkable
Investigations
CBC: Normal,K: 4.8, Na. 138,Cl : 92,Urea: 54,Cr: 1.1 ECG: rate: 82, rhythm: regular, axis: normal, normal QRS complex, ST elevation in AVR and V1 more than one small square with ST depression in inferolateral leads as shown in Fig.1
 |
| Fig.1 ECG of the index case |
Hospital course :
- We received this young man in cardiogenic shock following acute myocardial infarction.
- The patient was directly shifted to the critical care area within the ER and cardiology team contacted to activate Cath Lab.
- Meanwhile, the patient was started on NS fluids in both arms and nor-epinephrine was kept standby till cardiologist arrived at the ER.
- Vitals continued to be compromised. BP 65/40
- The Cath lab was busy as another 2 cases were going on there.
- The cardiologist preferred to start thrombolytic therapy and he ordered morphine for pain control as well.
- The patient arrested
- CPR was done for 40 minutes
- The patient started to bleed through the EET.
- Unfortunately, the patient could not be resuscitated and was declared dead.
Teaching message
Fill the tank in cardiogenic shock before you start vasopressors and chronotropic support.
Don’t give medication which will aggravate hypotension
Contributed by
Dr.Yasser Hussain Alnofaiey Assistant professor of Emergency Medicine, Taif University Contact Dr. Yasser: Twitter
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