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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 |
| #2018088 |
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aaa
cardiac tamponade d/t free wall rupture: 10h post-MI, low BP, tachycardia with low voltage, same pressures in chambers
but, a bit confused with systric RV pressure=30
doesn't it mean pul HTN?? wedge pressure is also in high limit of normal range |
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| * Re:most appropriate next step in management |
| #2018118 |
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it is due to fluid infusion causing increse pressure in right side of the heart and decrease left sided blood pressure (CWP=left atrial press;) so the answer will be diuresis ,if it is not progress ,we continue with dobutamine to promote vent contraction; if i am wrong ,pl correct me |
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| * Re:most appropriate next step in management |
| #2018193 |
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i wonder what would heart failure's picture be in context with the pressures in the chamber. CWP should be elevated as in this case but what about the other chambers...? anybody please comment.. i just went through this Q and chose dopamine as the answer. |
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| * Re:most appropriate next step in management |
| #2018199 |
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"i choose pericardiocentesis due to EKG sign " low voltage"+ hemodynamic instability, for diagnosis have a doubt between pericarditis ( constrictive or tamponade and RIGHT Infarct) not easy to differentiate and or to distinguish between them ( from this case), in case of tamponade or constrictive pericarditis ( end diastolic pressure is equal in all 4 chambers + pulmonary artery). |
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| * Re:most appropriate next step in management |
| #2018464 |
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why can he has cardiac temponade? rupture of ventriclal cann't happen acutely after infarct,after 2-7 days? this case may be rt vent infarction causing lower BP ,and we need to give fluids but if more than needed rt vent can''t pump out fr it's chamber and showing with pressure difference between chambers.. so to reduce preloads give diuresis again..
between dopamine and dobutamine ,,,dobu,increase inotropic effects whereas dopa increase only afterload....it's my thinking, sorry if i'm wrong
please post yr explanation!!!!!!! |
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