Male patient with inferior infarct. Started on streptokinase, and after
about 20 minutes starts to become hypotensive and bradycardic. No obvious
sign of bleeding. Nurse monitors carefully in the hope will settle but
gets concerned when bp not picked up by automatic sphyg although still
palpable and pulse is 34, sinus rhythm and no evidence of any sort of
conduction disturbance.
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Maybe I am a little old fashoned, but I would examine the patient first.
Observations are useful indicators, but without clinical examination they do
not impress me much and could become a potential source of confusion.My main
question would be: how is the patient feeling, and how does he look?
Blood pressure taken by a machine could be really unreliable. In this
scenario, it should be promptly measured again with the stethoscope,
preferably by the doctor.
1. Run in fluid in case there is a bleed?
Hypotension and bradicardia: bleeding? Uhm...sounds unlikely.
Intra-abdominal bleeding can be accompanied by relative bradicardia, but a
rate of 34 in a patient with no other signs of haemorrhage would not make me
feel at ease with this diagnosis.
2. Stop the infusion until pulse and bp recovers?
Yes, or at least I would initially slow it down.
3. Treat with hydrocortisone and antihistamines?
Anaphylactic shock? Again, I would expect hypotension and tachicardia, or
relative bradicardia.
4. Treat with atropine?
Yes, I would.
5. Do nothing?
Nothing??? NEVER! Do something, please.
6. Do something else or a combination of some of the above?
Elevate the foot of the bed to favour venous return.
Involve the cardiologist on call ASAP.
Monitor CVP. Ideally, use a Swan-Ganz pulmonary artery catheter.
Consider pacing for bradicardia unresponsive to atropine.
Interesting exercise. Can we have more, please?
Marcello della Corte, MD
Locum Registrar in Accident and Emergency
Wycombe Hospital
High Wycombe, Bucks
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