Atypical Presentation of an Acute MI
A 68 year old female presented to the ER with complaints of abdominal pain and vomiting for three days. Past medical history was significant for end stage renal disease on hemodialysis, high blood pressure, diabetes, and high cholesterol.
Her past surgical history was significant for bilateral below the knee amputations (BKA), coronary artery bypass graft (CABG), and amputations of two fingers on her left hand.
The patient was worked up as a case of abdominal pain, we drew the regular labs, CBC, BMP, amylase, and lipase, and we also gave her oral contrast to drink in preparation for an abdominal CT. We also gave her pain and nausea medication. My initial impression as I assessed her was that she was definitely very sick. She could not tell me much about her history, most of we got from her prior visit records, and I was unable to ascertain when her last dialysis appointment had been. I placed her on the cardiac monitor because I was concerned about her past cardiac history, and because she looked really sick. I also obtained an EKG and an accucheck.
Her initial lab results revealed elevated BUN and creatinine values as expected, and her electrolytes were also out of whack. Most significantly her potassium level was markedly elevated at 7.0.
I have seen physicians manage hyperkalemia in different ways. The attending that night elected to use Kayexalate PO and 1 amp Calcium chloride IV push. Knowing that she was a renal patient, and given the potential cardiac toxicity of calcium chloride, I verified the order with the doc to make sure this was what he wanted to do. I injected the dose into a small 50ml bag of 0.9% NSS and infused it over 20 minutes.
An hour after I had given her the Kayexalate and the calcium chloride had completed infusing, the patient became very restless and agitated, stating she could not breathe and felt "not right." I quickly obtained an accucheck, an EKG, and a set of vital signs. I placed her on 2L of oxygen. All her signs were stable, there were no changes in her EKG, and her accucheck was 146. She was midly tachycardic on the heart monitor, but she was very diaphoretic and unable to verbally respond to my questions. Very shortly after this the patient decompensated rapidly, appeared to go into a tonic clonic seizure with foaming at the mouth, and in a matter of minutes she became completely unresponsive. We could not obtain a BP or a pulse ox reading, but all pulses remained palpable. We intubated her to protect her airway, drew another chemistry panel, and also drew a set of cardiac enzymes. The patient progressed into a bradycardic arrest and we had to perform CPR.
After several doses of atropine and epinephrine we were able to obtain a pulse, a BP, and she begun to perfuse and we could get a pulse ox reading. Her repeat potassium level drawn just before we intubated her came back at 5.9, and her troponin came back at 3.8.
At this point my shift was ending and I had to hand her care over to another nurse so she could be transferred to the ICU. When I came back to work after two nights, I looked up her chart and got an update.
Her second and third set of cardiac enzymes had troponins trending upwards with the third troponin being 83. Her abdominal CT was unremarkable, and her potassium level was down to 4.8. She was being managed as having a non-ST elevation MI (NSTEMI) secondary to hyperkalemia and acidosis.
I have reflected a lot on this case, being that this was the first time I watched a patient assigned to me decompensate so rapidly.
Things I'm glad I did:
- Obtained a baseline EKG and accucheck on arrival even though they weren't ordered
- Placed her on a cardiac monitor even though it was not ordered
Things I wonder about:
- Did the calcium chloride accelerate or trigger whatever cardiac event was happening leading to an MI, or was her body building up to the MI all on its own?
- Had we drawn a set of cardiac enzymes with her initial labs, would the troponin have been positive, and would this have made a difference in the final outcome?
- Would it have helped if we had been able to ascertain for a fact that she had missed a dialysis appointment (which I suspect she had)? If we had dialyzed her emergently on arrival to the ER, would it have made a change in the outcome?
The patient remained stable in the ICU for a few days and was subsequently extubated and transferred to a regular floor.
Privacy/HIPAA Disclaimer
The cases and persons that are described in these pages are composites, none representing any one particular patient, person, or case. While the medical facts are all true and accurate, I have edited and doctored and composited enough that none of the personal descriptions, family settings, or any other distinguishing features are representative of any real actual person. In other words, I am not violating any HIPAA laws and regulations on this website, and the privacy of all my patients is completely protected. Any resemblance to any living person is completely accidental and unintentional.
Nice, i like your articles a
Nice, i like your articles a lot and will be excited to read more
Interesting case, Elderly
Interesting case, Elderly people with multiple co-morbiditeis tend to present in atypical manner and diabetes is a big risk factor for atypical presentation of MI. I once had a lady of similar age who walked into my office complaining of some gastric distress. I just wanted to be sure so I asked for an ECG. And to my surprise I found that she had had an Inferior wall MI. So in a diabetic any pain in the chest or abdomen should arrouse the suspicion of coronary syndrome. And the lady in this post is at a very high risk of coronary disease. She has diabetes and kidney failure which confer a very high risk of coronary disease and she has undergone a prior CABG as well as BK amputations, so I think a ECG and Trop T should have been ordered in the ER itself.
Atypical MI Presentation
I can recall a case involving a mid-40's male presenting to the Emergency Department with bilateral hip pain. He denied any recent trauma or injury and stated that pain presented suddenly around 2 hours prior to arrival.He was immediately placed in a trauma bed (only bed available at the time)and vital signs were obtained. His initial BP was 95/40. His SpO2 read 95% on room air, respiratory rate of 25-30 per minute, and a heart rate of 56. He appeared diaphroetic, but I had a feeling that his case was more complicated than idiopathic pain. He was immediately connected to the cardiac monitor when ST elevation was noted in the prominent lead (Lead II). An EKG was performed with ST elevation noted in Leads II, III, and AVF, indicative of an inferior MI. He was quickly stabilized and transferred to interventional cardiology, where he was treated and made a full recovery. Though his case was typical, as far as the vital signs that may be exhibited in an inferior MI, he never complained of any other symptoms besides the bilateral hip pain.
Interesting presentation
RBeavRN, it's amazing to me how many different ways MIs can present. In this case bilateral hip pain, which normally would not lead to high index of suspicion for a cardiac event. Good idea to get an EKG!
Glad you went with your gut on that.
Great article. That had to have been so scary for you and the patient I'm sure. Glad you went with your gut on that.
Instincts can be life-saving
His obvious distress, diaphroesis and bradycardia, immediately led me to believe that he was experiencing a cardiac event. Luckily, my intuition was correct, as I believe that the longer you nurse, the more distinctive you become with these situations. I am starting my 8th year of emergency nursing, and I learn each shift I work.
Post new comment