A 55-Year-Old Construction Worker Is Brought to the Emergency Department

A 55-year-old construction worker is brought to the emergency department with sudden onset of diaphoresis and severe chest discomfort.  His symptoms woke him up 3 hours earlier.  On arrival, his blood pressure is 98/60 mm Hg, pulse is 86/min, and oxygen saturation is 98% on 3 L oxygen by nasal cannula.  He has persistent chest discomfort, and his skin is cold and clammy.  Neck veins are mildly distended.  Lung fields are clear and cardiac examination is unremarkable.  His initial EKG reveals 3-mm ST segment elevation in leads II, III, and aVF.
He is referred for emergency cardiac catheterization and is found to have an acute occlusion of the proximal right coronary artery.  There is mild, diffuse coronary atherosclerosis present in the left coronary circulation.  Left ventriculography reveals mild hypokinesis of the inferior wall with an LV ejection fraction of 55%.  He undergoes primary percutaneous coronary intervention with a bare metal stent and has TIMI II flow restored at the end of the procedure.  He is started on aspirin, prasugrel, atorvastatin, and intravenous eptifibatide and is transferred to the coronary care unit.
Thirty minutes later, his blood pressure drops to 80/54 mm Hg.  He has minimal residual chest discomfort but no other symptoms.  His physical examination is unchanged.  An urgent EKG shows minimal, less than 1 mm, persistent ST-segment elevation along with small Q waves in inferior leads.
Which of the following is the next best step in management of this patient?

A) Call for a pericardiocentesis tray
B) 500-mL bolus of normal saline
C) Intra-aortic balloon pump insertion
D) Start dobutamine infusion
E) Stat CT scan of abdomen and pelvis

Correct Answer:

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