Atyp|ca| resentat|on of an Acute MI

A 68 year old female presenLed Lo Lhe L8 wlLh complalnLs of abdomlnal paln and vomlLlng for Lhree days asL medlcal
hlsLory was slgnlflcanL for end sLage renal dlsease on hemodlalysls hlgh blood pressure dlabeLes and hlgh cholesLerol
Per pasL surglcal hlsLory was slgnlflcanL for bllaLeral below Lhe knee ampuLaLlons (8kA) coronary arLery bypass grafL
(CA8C) and ampuLaLlons of Lwo flngers on her lefL hand
1he paLlenL was worked up as a case of abdomlnal paln we drew Lhe regular labs C8C 8M amylase and llpase and
we also gave her oral conLrasL Lo drlnk ln preparaLlon for an abdomlnal C1 We also gave her paln and nausea
medlcaLlon My lnlLlal lmpresslon as l assessed her was LhaL she was deflnlLely very slck She could noL Lell me much
abouL her hlsLory mosL of we goL from her prlor vlslL records and l was unable Lo ascerLaln when her lasL dlalysls
appolnLmenL had been l placed her on Lhe cardlac monlLor because l was concerned abouL her pasL cardlac hlsLory and
because she looked really slck l also obLalned an LkC and an accucheck
Per lnlLlal lab resulLs revealed elevaLed 8un and creaLlnlne values as expecLed and her elecLrolyLes were also ouL of
whack MosL slgnlflcanLly her poLasslum level was markedly elevaLed aL 70
l have seen physlclans manage hyperkalemla ln dlfferenL ways 1he aLLendlng LhaL nlghL elecLed Lo use kayexalaLe C
and 1 amp Calclum chlorlde lv push knowlng LhaL she was a renal paLlenL and glven Lhe poLenLlal cardlac LoxlclLy of
calclum chlorlde l verlfled Lhe order wlLh Lhe doc Lo make sure Lhls was whaL he wanLed Lo do l ln[ecLed Lhe dose lnLo a
small 30ml bag of 09 nSS and lnfused lL over 20 mlnuLes
An hour afLer l had glven her Lhe kayexalaLe and Lhe calclum chlorlde had compleLed lnfuslng Lhe paLlenL became very
resLless and aglLaLed sLaLlng she could noL breaLhe and felL noL rlghL l qulckly obLalned an accucheck an LkC and a
seL of vlLal slgns l placed her on 2L of oxygen All her slgns were sLable Lhere were no changes ln her LkC and her
accucheck was 146 She was mldly Lachycardlc on Lhe hearL monlLor buL she was very dlaphoreLlc and unable Lo verbally
respond Lo my quesLlons very shorLly afLer Lhls Lhe paLlenL decompensaLed rapldly appeared Lo go lnLo a Lonlc clonlc
selzure wlLh foamlng aL Lhe mouLh and ln a maLLer of mlnuLes she became compleLely unresponslve We could noL
obLaln a 8 or a pulse ox readlng buL all pulses remalned palpable We lnLubaLed her Lo proLecL her alrway drew
anoLher chemlsLry panel and also drew a seL of cardlac enzymes 1he paLlenL progressed lnLo a bradycardlc arresL and
we had Lo perform C8
AfLer several doses of aLroplne and eplnephrlne we were able Lo obLaln a pulse a 8 and she begun Lo perfuse and we
could geL a pulse ox readlng Per repeaL poLasslum level drawn [usL before we lnLubaLed her came back aL 39 and her
Lroponln came back aL 38
AL Lhls polnL my shlfL was endlng and l had Lo hand her care over Lo anoLher nurse so she could be Lransferred Lo Lhe
lCu When l came back Lo work afLer Lwo nlghLs l looked up her charL and goL an updaLe
Per second and Lhlrd seL of cardlac enzymes had Lroponlns Lrendlng upwards wlLh Lhe Lhlrd Lroponln belng 83 Per
abdomlnal C1 was unremarkable and her poLasslum level was down Lo 48 She was belng managed as havlng a nonS1
elevaLlon Ml (nS1LMl) secondary Lo hyperkalemla and acldosls
l have reflecLed a loL on Lhls case belng LhaL Lhls was Lhe flrsL Llme l waLched a paLlenL asslgned Lo me decompensaLe so
rapldly
1hlngs lm glad l dld
CbLalned a basellne LkC and accucheck on arrlval even Lhough Lhey werenL ordered
laced her on a cardlac monlLor even Lhough lL was noL ordered
1hlngs l wonder abouL
uld Lhe calclum chlorlde acceleraLe or Lrlgger whaLever cardlac evenL was happenlng leadlng Lo an Ml or was her body
bulldlng up Lo Lhe Ml all on lLs own?
Pad we drawn a seL of cardlac enzymes wlLh her lnlLlal labs would Lhe Lroponln have been poslLlve and would Lhls
have made a dlfference ln Lhe flnal ouLcome?
Would lL have helped lf we had been able Lo ascerLaln for a facL LhaL she had mlssed a dlalysls appolnLmenL (whlch l
suspecL she had)? lf we had dlalyzed her emergenLly on arrlval Lo Lhe L8 would lL have made a change ln Lhe ouLcome?
1he paLlenL remalned sLable ln Lhe lCu for a few days and was subsequenLly exLubaLed and Lransferred Lo a regular
floor