A 65-year-old man with a history of hypertension and coronary artery disease presents to the emergency department with a 2-hour history of severe chest pain radiating to his left arm. The pain began suddenly while he was resting. He describes it as a crushing sensation, 9/10 in intensity, and is associated with nausea and diaphoresis. His medications include aspirin, metoprolol, lisinopril, and atorvastatin. On arrival, his blood pressure is 90/60 mmHg, heart rate is 50/min, respiratory rate is 20/min, and oxygen saturation is 94% on room air. Physical examination reveals cool, clammy skin and distant heart sounds. An ECG shows 2 mm ST elevation in leads II, III, and aVF.

Which of the following is the most appropriate initial management step for this patient?

A) Administer intravenous nitroglycerin
B) Start high-dose atorvastatin
C) Perform immediate pericardiocentesis
D) Administer intravenous fluids
E) Give intravenous beta-blockers

Answer: D) Administer intravenous fluids

🧠 Summary:

Inferior MI with RVI → ⬇️ right ventricular output → ⬇️ preload to left heart → systemic hypotension.

IV Fluids ↑ preload and improve cardiac output.

RCA Occlusion → Inferior MI

🧠 Key Insight: RCA supplies right ventricle + inferior wall.

⬇️

Right Ventricular Infarction (RVI)

🧠 Right ventricular contractility ↓ (↓ pumping ability).

⬇️

↓ Right Ventricular Output

🧠 Key Insight: Right ventricle can't pump blood into pulmonary circulation.

⬇️

↓ Preload to Left Ventricle

🧠 Key Insight: Less blood to left ventricle from lungs → ↓ left-sided cardiac output.

⬇️

Systemic Hypotension

🧠 Key Insight: BP ↓ (systemic blood flow ↓).

⬇️

Bradycardia (often seen)

🧠 RCA also supplies SA node → conduction issues.

⬇️

Compensatory Mechanism

Vasoconstriction (cool, clammy skin) to maintain BP

⬇️

Corrective Management: IV Fluids (Answer D)

🧠 Key Insight: IV fluids ↑ preload to restore right ventricular function → ↑ cardiac output → BP ↑.

Why Other Options are Incorrect:

A) IV Nitroglycerin

🧠 Nitroglycerin ↓ preload → worsens hypotension due to further reduction in right ventricular filling.

B) High-dose Atorvastatin

🧠 Statins help long-term by stabilizing plaques, but don’t address acute hypotension.

C) Pericardiocentesis

🧠 No evidence of pericardial effusion or tamponade; heart sounds distant due to low cardiac output, not fluid.

E) IV Beta-blockers

🧠 Beta-blockers ↓ HR and contractility, further ↓ BP, worsening shock.

Flashcards

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