Rapid Response. 59 y/o Male admitted to tele floor for NSTEMI. Initial CP in ED improved but has now worsened. He has ST depressions in II, III, F, V5-6. Trop 0.95->2.9. MB 45. SBP has dropped into the 70s. He was Tachy, now Brady in 50s. What are your next steps?
Apparent inferior NSTEMI with hypotension/cardiogenic shock. Suspicious for RV infarction, so… check PCW, JVD and lungs sounds. Maybe, place posterior leads and recheck EKG to verify. Start normal saline infusion and inotrope, possibly dobutamine
ReplyDeleteFirst, address the ABCs to assess stability. Does he have a pulse and is he breathing? If no, then start CPR and call a code. If yes, then see if he has any arrhythmia other than sinus brady. He is unstable d/t hypotension, bradycardia and CP in the setting of recent NSTEMI; therefore I would choose electricity to pace over Atropine. If the pacing didn't work then I would try atropine. If his pressure doesn't come up then I would give Dobutamine for cardiogenic shock. If no improvement, I would consult cardiology to see if he needs urgent heart cath for possible inferior MI developing.
ReplyDeleteSources: AHA ACLS guidelines, OnlineMedEd Intern Guide
Kate Ryan
Check code status. Obtain updated vitals including O2 saturation. Assess patient for orientation, ability to protect airway, breath sounds, work of breathing, JVD, new murmur not previously documented on exam, etc. Brief ROS while performing exam if patient is able to answer questions. Also obtain patient's PMHx from patient's chart and nurse and ask about any other acute changes prior to rapid response being called. Check old labwork from ER particularly electrolytes, ABG if done. Check administered medications to see if patient had been given anything such as beta-blockers which could have caused these changes. Repeat EKG. Obtain ABG to check for acidosis as well as CO2 retention and hypoxia, repeat troponin if it has been 3 hours, repeat BMP if there were electrolyte abnormalities, check accucheck for hypoglycemia, STAT CXR. Check to see if d-dimer or CT angio had been ordered in ER to r/o PE. Start NS bolus wide open for hypotension. If patient is unresponsive and full code intubate for airway protection. For symptomatic/unstable patient place pacer pads from crash care and transcutaneously pace. Transfer patient to ICU for pacing / likely need for dobutamine. Consult cardiology and start heparin gtt if not already done before rapid response called. STAT bedside echo to assess for wall motion abnormalities as well as RV strain. Notify patient's family / contact person of this acute change in his condition and that we will be moved to ICU.
ReplyDeletePatient is having inferior wall STEMI with concurrent hypotension. First thing that needs to be addressed is airway, breathing and circulation. If airway is intact and protected and patient is ventilating fine then his pressure needs to be addressed. Patient needs to be given normal saline bolus. If the rate does not respond, they are unstable and could be paced from the crash cart. Patient could benefit from a stat echo to see if there is any abnormal wall motion or wall rupture. If there is no rupture and the BP and HR respond to the fluid then they could still benefit from PCI within the 90 minute window. Patient would be loaded with aspirin and Ticagrelor. He would need dual antiplatelet therapy for at least 12 months depending on the stent and some form of anticoagulation. If the patient is not a cath candidate then he will need to be medically managed with heparin drip for at least 48 hours and placed on antiplatelet therapy. If there is wall rupture then the patient will need surgery followed by a stay in the ICU possible with pressures or a balloon pump. Patient would likely benefit from cardiology consult and follow up in outpatient.
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