215.The answer is b. (Tintinalli, pp 343-359.) This patient is in
cardiogenic shockfrom a right ventricular infarction. The ECG shows ST-
segment elevation in leads II, III, and aVF indicating the patient is having
aninferior wall MI.Approximately 30% of inferior MIs involve the RV.
A right-sided ECG would confirm the diagnosis. RV infarction results in
reduced right ventricular end-systolic pressure, ultimately leading to decreased
cardiac output. Patients with RV infarctions are therefore dependent on preload
to maintain cardiac output. In this case, nitroglycerin, a powerful preload
reducer, pushed this patient into cardiogenic shock. Patients with RV infarction
and hypotension should be treated with IV normal saline to support preload.
Dobutamine may also be necessary to support the BP. Furthermore, this patient
is having an acute ST-segment elevation MI and may be a candidate for percuta-
neous coronary intervention or fibrinolytics.
(a)It is imperative to remember the relationship of inferior MI and RV
failure and not discount hypotension after nitroglycerin and morphine to
medication side effects alone. Papillary muscle rupture (c)is also associated
with inferior wall MI, but occurs 3 to 5 days after the primary infarction.
Patients present with new-onset dyspnea, exercise intolerance, and new mur-
mur on examination. Free wall rupture (d)is a serious complication of MIs
occurring 1 to 5 days after the primary event. Patients complain of sudden
onset of tearing, severe chest pain and usually present in cardiogenic shock
secondary to cardiac tamponade. Rupture of the interventricular septum
(e)is more common in patients with recent anterior wall infarctions. These
patients present with chest pain, shortness of breath, and a new murmur.
216.The answer is c.(Tintinalli, pp 501-505.)Abdominal pain in the
elderly can be challenging for many reasons, including poor histories and
deviation from classic presentations of diseases. However, abdominal pain in
patients over 65 must be taken seriously since 25% to 44% require surgical
intervention and more than 50% require admission to the hospital. This CXR
reveals free air under the right diaphragm,likely from a perforated viscous.
This is a surgical emergencyand the surgical service should be contacted.
Antibiotics(a)and a central venous line (d)are appropriate and can be
started after the surgical team has been notified. It is important to obtain large-
bore IV access for this patient. If peripheral lines are not obtained, then a cen-
tral venous line should be inserted. A CT scan (b)is not necessary in this
patient, especially with her low BP. She should be taken directly to the OR for
an exploratory laparotomy. Although the patient has a benign abdominal
examination, the caretakers report and her low BP is worrisome and sending
the patient home (e)prior to a complete workup would be a mistake.
234 Emergency Medicine