Post-Cath Instability: Rapid Evaluation and Management in the ICU

What do you do when a patient returns from the cath lab hypotensive and unstable? In this episode of SoCCC Pre-Rounds, critical care cardiologists Dr. Ann Gage and Dr. Zach Il'Giovine join host Dr. Elliott Miller to break down the management of post-catheterization hypotensive emergencies. This conversation delves into rapid assessment, differential diagnosis, and life-saving interventions in the acute care setting.The experts emphasize the importance of taking a moment to gather context before rushing to the bedside. Was it a PCI, EP study, or structural intervention? This pause allows for a more focused differential diagnosis, covering complications such as vascular issues (groin hematoma, retroperitoneal bleed), cardiac tamponade, and acute stent thrombosis. A standout takeaway: manual pressure is your first-line tool for managing bleeding, and don’t hesitate to call the proceduralist early. They also highlight when to order a CT scan (pro-tip: non-contrast first) and the principles behind massive transfusion protocols.This episode offers actionable insights for handling hypotensive emergencies with confidence and precision. Key TakeawaysBuild a differential based on the cath details: arterial, venous, pericardial?Retroperitoneal bleed is high on the list for sudden post-cath hypertension.First move: Is the patient in extremis? If yes, act. If not, think.Groin pain or back pain? Start with pressure and basic labs.For massive bleeds: use balanced transfusions and proper IV access.Most important treatment for groin bleeds? Manual pressure.In This Episode[00:00] Introduction[00:56] Meet the guests: Dr. Ann Gage and Zach Il'Giovine[02:09] Gathering info before seeing post-cath patient[03:46] Building the differential diagnosis[08:13] Physical exam and bedside assessment[09:57] Hemodynamic assessment and initial workup[16:00] Massive hemorrhage and transfusion protocols[17:05] Procedural complications and communication[19:55] Manual pressure crucial for groin bleeds[21:11] Conclusion and take-home messagesNotable Quotes[04:06] "I was told once by a medicine resident that if you were a good resident, you would have two or three things on your differential, but if you were great, you would appear at the bedside with at least 10 things on your differential." — Dr. Ann[00:13:55] "Nothing really makes me madder than coming in the morning and seeing that the residents gave contrast to ten people, when if you've got a hemodynamically significant bleed, you do not need contrast." — Dr. Elliott[00:20:53] "On more than one occasion, manual pressure has saved lives." — Dr. Zach Dr. Ann GageDr. Ann Gage is a critical care and interventional cardiologist at Centennial Heart in Nashville. She bridges the cath lab and CICU with expertise in both patient care and procedural nuance.Dr. Zach Il'GiovineDr. Zach Il'Giovine is a heart failure and critical care cardiologist at Centennial Heart. He focuses on managing complex ICU patients, procedural complications, and bridging multidisciplinary care.Resources and LinksBecome a member of the Community: https://www.soccc.org/subscribeDr. Ann Gage https://centennialheart.com/https://www.linkedin.com/in/ann-gage-b7036831https://x.com/anngagemd?lang=enDr. Zach IlGiovinehttps://centennialheart.com/https://www.linkedin.com/in/zachary-il-giovinehttps://x.com/zilgiovinemd?lang=enDr. Elliott Millerhttps://x.com/ElliottMillerMDhttps://www.soccc.org/Supported By:This episode is made possible by unrestricted support from Zoll LifeVest — thanks for keeping high-impact education free for our community.DisclaimerThis podcast is not medical advice, just candid, practical discussions about what your hosts do every day in the CICU. Always consult your supervising team and current guidelines before applying any interventions.