A 56-year-old woman who is post-operative day #1 after a laparoscopic cholecystectomy complains of chest discomfort. The patient reports that in the early hours of the morning, she was awakened from sleep with nausea, one episode of vomiting, and persistent burning in her chest. Her only medical history includes hypertension, which has been well-controlled with medication. Her other current medications include ondansetron, acetaminophen, and hydrocodone.
Her temperature is 37.9 C (100.2 F) , blood pressure is 92/60 mm Hg, heart rate is 90 /min, and respirations are 18 /min. Her BMI is 31 kg/m². She is in moderate distress and appears anxious. There is no murmur on cardiac examination and bilateral fine crackles are heard at the lung bases. Her abdomen is distended and non-tender with an incision that is clean and intact. Bowel sounds are diminished. There is no rebound tenderness or rigidity. There is no peripheral edema.
A 12 lead EKG is performed and displayed below:

Which of the following would be the most appropriate next step in managing this patient?

Question

A 56-year-old woman who is post-operative day #1 after a laparoscopic cholecystectomy complains of chest discomfort. The patient reports that in the early hours of the morning, she was awakened from sleep with nausea, one episode of vomiting, and persistent burning in her chest. Her only medical history includes hypertension, which has been well-controlled with medication. Her other current medications include ondansetron, acetaminophen, and hydrocodone.
Her temperature is 37.9 C (100.2 F) , blood pressure is 92/60 mm Hg, heart rate is 90 /min, and respirations are 18 /min. Her BMI is 31 kg/m². She is in moderate distress and appears anxious. There is no murmur on cardiac examination and bilateral fine crackles are heard at the lung bases. Her abdomen is distended and non-tender with an incision that is clean and intact. Bowel sounds are diminished. There is no rebound tenderness or rigidity. There is no peripheral edema.
A 12 lead EKG is performed and displayed below:

Which of the following would be the most appropriate next step in managing this patient?

Quizplus · Accepted Answer

This patient is having a perioperative ST elevation myocardial infarction (STEMI). The electrocardiogram is diagnostic and shows up to 5 mm of convex ST elevation in the anterior precordial and lateral limb leads along with characteristic reciprocal changes of ST depression in the inferior leads, suggestive of an occlusive thrombus in the left anterior descending artery (LAD). Current guidelines recommend that patients with STEMI undergo emergent reperfusion (preferably by angioplasty and stent, if available) without any delays in treatment. While being prepared for transport to the cardiac cath lab, patients should receive aspirin 325 mg (as 4 aspirin 81 mg chewed), unfractionated heparin, and a beta blocker (in the absence of contraindications). At cardiac cath, this patient did have an LAD thrombus which was removed and stented. A post-procedure EKG shows near resolution of the EKG changes. EKG changes (Choice B) The postoperative chest pain and diagnostic 12 lead EKG are highly suggestive of a cardiac etiology rather than a pulmonary embolism in this patient. (Choice C) Although beta blockers are generally indicated in acute coronary syndromes, this patient has an abnormally low blood pressure in the setting of a known history of hypertension, and should not acutely receive an intravenous beta blocker that could further lower her blood pressure. (Choice D) Although morphine is a reasonable option for pain control while awaiting reperfusion, there is no role for pantoprazole in this patient. (Choice E) Transthoracic echocardiogram could be useful to evaluate for acute valvular lesions, CHF, or sometimes a questionable diagnosis of acute coronary syndrome (i.e., non-diagnostic EKG). However, this patient has a diagnostic EKG for acute coronary syndrome and no murmur on exam to suggest valvular disease. Educational objective: Patients with STEMI should undergo prompt and emergent evaluation with cardiac catheterization (preferably with angioplasty and stent) and receive concurrent medical therapy with aspirin, heparin, and a beta blocker (if no contraindications exist). __________ References: ACC/AHA guideline update for the management of ST-segment elevation myocardial infarction. (http://www.ncbi.nlm.nih.gov/pubmed/19530638)

A 56-Year-Old Woman Who Is Post-Operative Day #1 After a Laparoscopic