12L. Old damage or acute RVI?

[OKparamurse]

Early 50's male at local dialysis center for syncope. Of course thinking they pulled off too much fluid too quickly. Staff states prior to any fluid removal pt collapsed while self-transferring from wheelchair to dialysis chair. Approximately 60 second downtime, no seizure activity. Last Tx was Wednesday, was scheduled for Friday and missed. 2 bp's obtained pta by staff, all 70s over 40s. Only c/o dizziness. I reach for a radial and palpate a thrrady regular pulse at a rate of about 70. I inquire, "About to pass out 'dizziness' or just a little lightheaded?" He states he just feels "a little fuzzy but otherwise fine." 2 12L obtained, one L sided and one with v4R. Hypotensive on my monitor as well, 74/47. BGL of 67 tx'ed with oral Glucose. 94% 3L NC. Pt states a significant cardiac hx to include 2 open heart surgeries, a triple bypass, advanced CAD, and a pacemaker/defib. It was a transport of less than 1.5 miles so I didn't have much time to run more than those two 12L before arriving at the ED.

I called this in as more of "Hey, this is what's going on and I'm suspicious of cardiac issues but not enough to activate Cath Lab." Was on the fence between old damage or acute RVI from presentation and pt Hx. ER Doc agreed and ordered stat troponin. Haven't heard back yet on the findings... Any thoughts?

 

[VFlutter]

My bet would be demand ischemia from the significant hypotension and known CAD. Nothing definitive enough to consider a cath lab activation IMO. You could argue elevation in V4R but it is slight at best. Could just be worsening RV failure.

Check Electrolytes and Cardiac Enzymes then Pacer Interrogation and possibly upgrade to a Bi-V pacer.

Syncope with evidence of RV strain is always a bad sign and PE should also be ruled out.

 

[OKparamurse]

My bet would be demand ischemia from the significant hypotension and known CAD. Nothing definitive enough to consider a cath lab activation IMO. You could argue elevation in V4R but it is slight at best. Could just be worsening RV failure.

Check Electrolytes and Cardiac Enzymes then Pacer Interrogation and possibly upgrade to a Bi-V pacer.

Syncope with evidence of RV strain is always a bad sign and PE should also be ruled out.

Surgery about 2 weeks prior for a fx'ed humerus as well. PE would definitely be in the realm of possibility. Hadn't even thought of that in terms of accompanying with the RV strain.

 

[Carlos Danger]

My bet would be demand ischemia from the significant hypotension and known CAD. Nothing definitive enough to consider a cath lab activation IMO. You could argue elevation in V4R but it is slight at best. Could just be worsening RV failure.

Check Electrolytes and Cardiac Enzymes then Pacer Interrogation and possibly upgrade to a Bi-V pacer.

Syncope with evidence of RV strain is always a bad sign and PE should also be ruled out.

This.

PE is always a possibility, but my suspicion for that would be low in this case.

 

[StCEMT]

As far as inferior, the Q waves suggest that is an old MI. I dont see any elevation to point towards a new one. The T waves are funky, but I'd expect that to be related to the demand ischemia already mentioned.

What I dont like is the 5~ days without dialysis + QRS that looks like it's approaching .12 + what appears to be a loss of p waves. The T waves don't have the peaked looked, but the other things aren't making me happy for what his K probably is.