14 June 2010

A Cautionary Tale

The patient's presenting ECG:
pre epi
The same patient's ECG after administration of IV epinephrine:
post epi
Note the difference?

For the uninitiated, the second tracing reveals new elevation of the ST-segments in the anterior and lateral leads suggesting an acute myocardial infarction. Epinephrine can do that, via a variety of mechanisms including sudden increase in cardiac workload with abruptly increased rate and afterload, and also coronary artery vasospasm, especially it there is pre-existent coronary artery disease present.

In this case the use of epi was, um, pretty justified: the patient brady'd down and became asystolic as we were attempting to intubate him for respiratory failure due to his severe metabolic acidosis from hemorrhagic shock from a GI bleed with a hematocrit of 18. So let's just say he had a lot going against him. (Also, he was 300 lbs and I was mighty happy to have the GlideScope which made a potentially very difficult intubation a non-event.)

The take-home message, however, is to be judicious with the use of epi, especially in older patients.

You have been warned.


  1. So do you hang a couple units of O neg and send this guy to the cath lab or is this something that would "resolve" on its own after the epi wears off?

    Is cardiac intervention indicated here?

    I'm an ER nurse in a smallish facility and love these little educational things you have. Our fair share of the weird stuff is few and far between.

  2. No cath lab for epi-induced MI, usually. Let the drug wear off and see what the ST segments do. In this case, he was GI bleeding, so he couldn't take the anticoagulation a cath would require, and he was grossly unstable for reasons other than cardiac, so cath would have been inappropriate in any case.

  3. Hi - I'm a pre-physician assistant student and I love reading your blog! Thanks for posting these cases - it's a great learning experience for me.

  4. He kinda looked a little ischaemic pre epi or am I over reading?


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