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On any given Sunday…

May 30, 2015

You are on call for CCU and you accept a patient for transfer: 56M with recent crescendo angina.  He was seen in a peripheral hospital where cardiology performed a diagnostic catheterization but did not perform angioplasty.  He has a >90% lesion in RCA.  He was loaded with aspirin and ticagrelor and transferred with advanced paramedics in stable condition.

On arrival to your unit, he is complaining of on-and-off chest pain, vitals show HR 90, BP 110/80, SpO2 95% on room air.  You notice a bulging mass in the right groin where they accessed for angiogram.

What are your concerns at this time?

You’re concerned that this patient with active untreated coronary artery disease may potentially have a significant bleed (including retroperitoneal extension), anemia and hypotension.  He’s taken long-acting anti-platelets so any potential surgery may lead to significant bleeding. He is stable now, but the RCA lesion could lead to conduction issues and RV failure, causing hemodynamic instability.

You place invasive monitors and a central line, and you arrange for CT angio to examine the extent of the bleeding. CT shows a pseudoaneurysm with some stranding in the retroperitoneum but no extravasation of IV contrast on CT.

While he’s being transferred off the CT table, he suddenly loses consciousness.

What is your differential diagnosis and how will you manage the situation?

Remember there are no right or wrong answers. Please tag your tweets with #gasclass!

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