Chest pain, pelvic and abdominal pain, hypotension, and severe ischemia on the ECG

An elderly male was lethargic at the nursing home and complained of some pelvic pain, but then also chest pain and abdominal pain.  He was hypotensive.  His medications include beta blockers.BP on arrival was 66/31, pulse 80, saturations 90% room air.  The patient was lethargic and shocky.An ECG was recorded:There is severe diffuse ST depression of subendocardial ischemia, with the obligatory reciprocal ST Elevation in aVR.One might also think there are hyperacute T-waves in inferior leads, with reciprocal STD and T inversion in aVL.  A bedside echo showed good LV function, no pericardial effusion, and normal right ventricle.  There were no B lines and the inferior vena cava looked somewhat flat.Is this Acute Coronary Syndrome?  What do you think?The cath lab had been activated by the time I walked into the critical care area and saw this.However, I was skeptical that this was ACS.  Not all severe ischemia is due to ACS.  Shock/Hypotension can be the cause of ischemiaor the result of ischemia.How do we differentiate?If ACS is the cause, then shock/hypotension is cardiogenic shock.  Cardiogenic shock has 3 etiologies:1. pump failure2. dysrhythmia (too fast or too slow)3. valve dysfunctionThe rhythm is sinus.  The bedside echo showed good pump function.  There was no evidence of valve dysfunction on our bedside echo.Because of the above considerations, I thought ACS was very unlikely.  I suspected some other catas...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs