A 46-year-old man with a history of familial hypercholesterolemia is admitted to the hospital for chest pain. He is found to have a massive myocardial infarction and undergoes PCI. The following day, the patient becomes hypotensive, and on examination he has distant heart sounds.
Which of the following should be avoided in this patient?
A. IV normal salineImmediate pericardiocentesis. This patient is presenting with a complication of a massive MI, which is ventricular free wall rupture leading to cardiac tamponade. This usually occurs within the first few days after an MI and presents with Beck’s triad of cardiac tamponade: hypotension, distended neck veins, and muffled/distant heart sounds. Free wall rupture leading to tamponade may also present with pulseless electrical activity. As blood accumulates in the pericardial sac, it exerts pressure on the heart and causes an equalization of pressure within the four chambers. During inspiration, blood is drawn into the right ventricle due to the negative intrathoracic pressure, and the interventricular septum deviates into the left ventricle and reduces left ventricular preload, and therefore the cardiac output. A paradoxical elevation in jugular venous pressure during inspiration may be seen in cardiac tamponade, but is also seen in other conditions including constrictive pericarditis (Kussmaul sign). This is a life-threatening situation, and immediate surgery is often necessary.
(D) The patient is hemodynamically unstable, and all the choices except pericardiocentesis are appropriate in this setting. (A) IV fluids can increase preload for adequate filling of the ventricles, which can help to offset the decreased cardiac output. (B) Inotropic agents may be necessary to support the blood pressure since he is hypotensive. Immediate pericardiocentesis is not a good option in this case, since it will not correct the underlying problem (a hole in the ventricular wall); drawing off a small amount of fluid in the setting of pulseless electrical activity may be appropriate, but in this scenario the patient should undergo immediate surgery to correct the ventricular defect.