A 72-year-old man arrives at the emergency department via ambulance with sudden-onset, sev… — USMLE Step 2 CK

A 72-year-old man arrives at the emergency department via ambulance with sudden-onset, severe respiratory distress that woke him from sleep $45$ minutes ago. He has a history of poorly controlled essential hypertension, hyperlipidemia, and a 40-pack-year smoking history. Temperature is $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure is $225/118$ mm Hg, pulse is $112$ /min, and respirations are $28$ /min. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. He is diaphoretic, speaking in one-word sentences, and using accessory muscles of respiration. Jugular venous distention is present when sitting upright. Auscultation reveals diffuse bilateral expiratory wheezes and bibasilar crackles. Cardiac examination shows regular tachycardia with a prominent S3 gallop. The electrocardiogram displays sinus tachycardia and voltage criteria for left ventricular hypertrophy without ischemic ST-segment or T-wave changes. Which of the following is the most appropriate next step in management?

Administer intravenous nitroglycerin and furosemideAnswer
B
Administer nebulized albuterol and intravenous methylprednisolone
C
Administer intravenous ceftriaxone and azithromycin
D
Administer intravenous metoprolol
E
Perform immediate computed tomography angiography of the chest

Answer

Administer intravenous nitroglycerin and furosemide

This patient is presenting with a hypertensive emergency complicated by acute decompensated heart failure (ADHF), also known as flash pulmonary edema. The sudden, severe elevation in systemic vascular resistance (afterload) causes left ventricular end-diastolic pressure to rise, leading to fluid backup into the pulmonary circulation. The presence of an S3 gallop, jugular venous distention, and bibasilar crackles are classic signs of fluid overload and a failing left ventricle. The diffuse wheezing, often termed 'cardiac asthma', is caused by peribronchial edema compressing the small airways and is a common presentation of ADHF. The immediate management requires rapid preload and afterload reduction, best achieved with intravenous vasodilators (such as nitroglycerin) and loop diuretics (such as furosemide), often combined with noninvasive positive pressure ventilation.

Step-by-Step Solution

Identify the underlying clinical syndrome based on the presentation.

The patient is experiencing a hypertensive emergency complicated by acute decompensated heart failure (ADHF), specifically flash pulmonary edema.

Severe hypertension (

225/118

mm Hg), hypoxia, jugular venous distention, an S3 gallop, and bibasilar crackles strongly indicate a rapid increase in cardiac afterload causing fluid backup into the lungs.

Determine the cause of the wheezing.

The wheezing represents 'cardiac asthma', which is secondary to peribronchial edema compressing the airways, rather than primary bronchospasm from COPD.

Differentiating ADHF from a COPD exacerbation is critical; the presence of an S3 gallop and JVD makes ADHF the primary diagnosis despite the smoking history.

Select the appropriate pharmacologic intervention.

Intravenous vasodilators (e.g., nitroglycerin) and loop diuretics (e.g., furosemide) are the indicated treatments.

These agents rapidly decrease systemic vascular resistance (afterload) and venous return (preload), alleviating pulmonary congestion and improving oxygenation.

Key Concept

Hypertensive emergency presenting with acute decompensated heart failure requires rapid preload and afterload reduction.

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