Hypotension in a Patient With Myocardial Infarction

Vital Signs

• Temperature: 98.2 °F, axillary

• Blood Pressure: 60/44 mmHg

• Heart Rate: weak low volume pulse, at a rate of 140 beats per min (bpm)

• Respiratory Rate: 26 breaths per min

• Pulse Oximetry: 85% oxygen saturation on room air, up to 92% on 6 L NC.

Focused Physical Examination

The patient was an elderly female holding her chest in apparent distress. On auscultation of her chest, diffuse bilateral crackles were evident, along with prominent jugular venous distension. Central cyanosis was seen. Her abdomen was soft and non-distended. No peripheral edema was noted, and her extremities were cool to the touch.

Interventions

A cardiac monitor and pads were attached immediately, with telemetry showing narrow, complex, regular tachycardia. The patient was given a fluid bolus. EKG was obtained, which showed sinus tachycardia with persistent ST elevations in anterior leads. A complete blood count (CBC), electrolytes, lactate, and troponin levels were ordered. Chest X-ray revealed a globular cardiac shadow which was not present before. Stat consult page was sent to intensivist and cardiology for evaluation, as the patient was status post-cardiac intervention. In-house intensivist performed a bedside ultrasound which revealed a large pericardial effusion with evidence of chamber compression. Emergency pericardiocentesis was performed by the cardiothoracic surgery team at the bedside, with frank hemorrhagic output. The patient was provided with fluids and inotropic support and transferred urgently to the operating room for direct closure of suspected ventricular wall defect and a prosthetic pericardial patch.