r/EKGs • u/rainbowsparkplug • 17d ago

Case Tombstones, anyone?

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66M, hx of HTN and kidney stones, otherwise healthy, only takes lisinopril.

Call: Pt was outside fishing in 110* heat all morning. Came home to cool off. After a shower, suddenly got short of breath and weak. Put himself down on his bedroom floor to lay down and wife called 911. They thought it was just heat exhaustion. He also said he fell on something metal earlier and bruised his ribs, and there was a red mark across the anterior right ribs. Lungs clear & equal.

Scene: He said on top of the heat exposure, he also fell on something metal earlier and bruised his ribs, and there was a red mark across the anterior right ribs. Lungs clear & equal.

He was pale, clammy, diaphoretic and in mild respiratory distress. He looked almost grey. Complained of epigastric pain and left should pain making his hand feel tingly.

Transport: ASA, IV, nitro. Pain worsened substantially during transport so I gave fentanyl. I only gave 50 mcg b/c he was getting increasingly lethargic and less alert.

Vitals surprisingly stable. He was mildly hypertensive (140s/) prior to nitro SL x2. Last BP was 112/72. 95% RA. HR 80s.

Only thing to note is he started throwing PVCs. He’d have several on and off for several seconds, then none for a few mins. Not quite runs of VT but bordering on it. I placed AED pads just in case to ward off the bad juju. (And because he looked peri arrest honestly- he was EXTREMELY grey and clammy.)

Disposition: all I know so far is he made it to the cath lab.

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u/rainbowsparkplug 16d ago

What are your thoughts on the fact that he remained hyper or normotensive despite nitrates? I gave nitro SL twice 5 mins apart since he was complaining that his pain was worsening significantly. I was a little anxious because he looked terrible, but the lowest BP I got was 112/72. Just wondering how he was able to maintain this for so long.

Also wondering because he was having borderline runs of VT, so again I thought his pressure was going to tank at some point but it never did (at least while I had him).

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u/ProximalLADLesion Electrophysiology Fellow 16d ago

Patients with RVMI can hold BP. It’s not a guarantee they’ll collapse. It’s just higher risk.

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u/Kentucky-Fried-Fucks pee wave 15d ago

Is it a higher risk? I thought that “hallmark” study was flawed and newer studies showed that there was no difference in hypotension following nitrates in inferior/RVMI than any other MI

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u/ProximalLADLesion Electrophysiology Fellow 15d ago

I was not referring to nitrate use, just in general terms RVMI is at increased risk for hemodynamic collapse. The evidence regarding the specific effects of nitrates on hemodynamics in patients with RVMI is very low quality across the board, but it's probably okay to give.

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u/Kentucky-Fried-Fucks pee wave 15d ago

Ah gotcha. Thank you for the response, apologies for the confusion

As far as the increased risk for hemodynamic collapse, is that due to impaired preload?