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| * most appropriate next step in management |
| | #482705 |
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A 70-year-old man is brought to the emergency department with electrocardiogram changes
indicating an acute myocardial infarction. He is given aspirin and tPA and started on a heparin
drip. Vital signs are normal, and a beta-blocker, ACE inhibitor, and statin are also started. Ten
hours after hospitalization, the patient becomes confused, drowsy, and complains of mild
dyspnea. His blood pressure is now 65/50 mmHg, heart rate is 120/min, and respiratory rate is
25/min. Pulse oximetry is 80% on room air. He is transferred to the intensive care unit, where
he is intubated and begun on normal saline intravenous fluids. Electrocardiogram reveals sinus
tachycardia with low voltage. A pulmonary artery catheter is placed, and the following readings
are obtained;
Right atrial pressure =18 mm Hg
Right ventricular pressure= 30/18 mm Hg
Pulmonary capillary wedge pressure= 17 mm Hg
Which of the following is the most appropriate next step in management?
A. Arrange for pericardiocentesis
B. Continue current treatment
C. Continue intravenous fluids
D. Start diuretics
E. Start dopamine |
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| * Re:most appropriate next step in management |
| #2018501 |
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Southernberry fibrinous pericarditis may happened between day 1 to 7 of transmural MI.have also a doubt here between right vent MI and tamponade, due to ekg sign microvoltage+ equal diastolic pressure this may point toward pericarditis. |
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| * Re:most appropriate next step in management |
| #2019145 |
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Obviously A.
Pulmonary capillary wedge pressure= 17 mm Hg indicating no cardiogenic pulm edema. Likely chest examination is clear, so no pulm edema, and not due to acute MR (2/2 papillary muscle rupture). Pt has hypotension and tachycardia with clear chest and just had an MI. It's cardiac tamponade. The fact it's so acute, so it's not an inflammatory process, but most likely a free-wall rupture.
The pt should be continued on aggressive fluid resuscitation, and emergent pericardiocentesis should be done.
Now, things happened really so fast and the rupture occured 10 hours status post revascularization with tPA? Sounds kinda weird. But in these cases, you shouldn't think about how it happened, but how to manage it. |
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