Proximal RCA occlusion. Hypotension is the result of right atrial/ventricular dysfunction resulting in decreased pulmonary blood flow and therefore decreased blood flow to the left side the heart.
Without prior EKGs or further H&P there is certainly a large amount of speculation, but as there is some lengthening to the PR interval I suspect a rather large amount of sinoatrial node ischemia. You could trial atropine but I highly doubt it would do anything. I would be hesitant to consider epi as the increased oxygen demand probably isn't worth in inotropic or pressor effects. At this point I don't think that pacing is of good value, if the patient consistently bradies below 40, enters a escape rhythm, becomes persistently unconscious, or has a more unstable pressure then I would certainly consider it. Overall I wouldn't be that concerned about the bradycardia at this point, although this patient will certainly earn at least pacer wires in the cath lab, and there is a good change he will get an implanted pacer before leaving the hospital.
Hypotension can be supported by giving fluids to support preload. As the patient's poor pressure is likely cardiac in nature and not peripheral I wouldn't strongly consider epi, levo, neo, or vaso unless the patient enters entremis, but even then they are temporizing measures that are going to cost as much heart tissue as time is borrowed. I wouldn't consider dobutamine or even milrinone due to the patient's hypotension, although if absolutely necessary I would certainly favor the latter. Dopamine may be of benefit but to me would be a lower priority to almost any other treatment.
Rapid transport to the nearest appropriate cath lab. Cardiac activation. Large bore IV access x2. Fluids to support preload. ASA/clopidogrel, consider heparin if available. Pacer/defib pads are mandatory, radiolucent if your service has them. Titrate oxygen as appropriate. Serial EKGs and trop, not that it makes any difference in this patient's disposition. Consider fentanyl, although to be honest I'd be a hesitant given his presentation.
