A 62 year old gentleman found unresponsive - What should be the Best Course of Action?

A 62 year old gentleman with a history of diabetes mellitus, hypertension, and a renal transplant presents to the ED after being found unresponsive at office. His temperature is 37.6 C, blood pressure is 80/30, heart rate 130, respirations 25, and oxygen saturation 75% on room air. Physical examination reveals bilateral pulmonary rales, a S4 heart sound is present, and no murmurs could be auscultated. He is intubated for airway protection. ECG reveals sinus tachycardia with a LBBB. 



A Swan-Ganz catheter is inserted and the values are below:

Right atrial presssure - 8 mmHg
Right ventricular pressure - 38/8 mmHg
Pulmonary artery pressure - 42/22 mmHg
Pulmonary capillary wedge pressure - 26 mmHg
Cardiac output - 4.0 L/min
Cardiac index - 2.0 L/min/BSA

Which of the following is best course of action?

 A) Emergency Echocardiography

 B) Emergent cardiac catheterization

 C) Tissue plasminogen activator infusion (tPA)

 D) Glycoprotein IIb/IIIa infusion

Answer: B - Emergent Cardiac Catheterization

The patient depicted in the question presents with severe shock. His Swan-Ganz pressure readings shows low cardiac output and elevated PCWP which reflects cardiogenic shock.Late stage septic shock can actually appear similar when the heart begins to fail, however the presentation is more acute in case of septic shock. This patient is most likely having a large myocardial infarction causing left ventricular dysfunction and reduced cardiac output leading to hypotension. He must be taken emergently for cardiac catheterization to revascularize the culprit coronary artery. Cardiac catheterization with stenting has been shown to be superior to thrombolytics in patients with cardiogenic shock. Inotropes could sometimes be helpful to stimulate inotropy and cardiac output, however this can worsen ongoing myocardial ischemia as well. 

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