What is the most likely cause of the hypotension in this patient?
June 22nd, 2011 | 
Author: The hypotension in this patient is most likely due to the cumulative effects of the medications he has been given (morphine and NTG). The accumulation and potentiation of medications, especially in the elderly, is a common clinical problem in the acute care setting. The combination of morphine and NTG in this patient may have induced sufficient vasodilation to cause hypotension.
Bleeding is also a possible cause of the hypotension. The administration of IV heparin, aspirin, and platelet glycoprotein IIb-IIIa inhibitor agents may result in gastrointestinal bleeding and melanotic stools. The absence of jugular venous distention and a paradoxical pulse argues against tamponade, but these findings may be absent with vasodilation or volume depletion. A more worrisome possibility is hemorrhagic pericarditis, especially because a new friction rub is heard. If the hypotension does not resolve quickly with discontinuation of NTG and morphine, an echocardiogram is indicated to exclude cardiac tamponade.