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Difficulty: MediumCardiovascular System

An inpatient consultation is requested for a 73-year-old male on the orthopedic surgery ward who developed acute-onset respiratory distress. The patient was admitted 3 days ago for management of right lower extremity cellulitis and has been receiving intravenous cefazolin and continuous normal saline at 125 mL/hr. Medical history is significant for hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Temperature is 37.1°C (98.8°F), blood pressure is 165/95 mm Hg, pulse is 112/min, and respirations are 28/min. Pulse oximetry shows 88% on room air. Physical examination reveals a patient in moderate respiratory distress using accessory muscles. Jugular venous pulsation is visible 11 cm above the sternal angle. Lung auscultation demonstrates diffuse, bilateral end-expiratory wheezes with scattered bibasilar crackles. Cardiac auscultation reveals a regular tachycardia with a prominent early diastolic extra heart sound. Lower extremities show 2+ pitting edema bilaterally extending to the knees. Which of the following is the most appropriate next step in management?

  1. Administer intravenous furosemideAnswer
  2. B
    Administer nebulized albuterol and ipratropium
  3. C
    Administer intravenous methylprednisolone
  4. D
    Broaden antimicrobial coverage to piperacillin-tazobactam
  5. E
    Administer intravenous metoprolol

Answer

Administer intravenous furosemide
The correct answer is to administer intravenous furosemide. This patient is presenting with acute decompensated heart failure (ADHF) precipitated by continuous intravenous fluid administration. The key physical examination findings—elevated jugular venous pressure, an early diastolic extra heart sound (S3 gallop), bibasilar crackles, and pitting edema—strongly indicate left and right ventricular volume overload. The diffuse wheezing heard on auscultation represents 'cardiac asthma,' which occurs when interstitial pulmonary edema causes peribronchial fluid accumulation and airway narrowing. The most appropriate next step in management is rapid preload reduction with an intravenous loop diuretic.

Step-by-Step Solution

1
Analyze the patient's acute clinical presentation and recent hospital course.
The patient developed acute respiratory distress after receiving 3 days of continuous intravenous fluids, suggesting a hypervolemic state.
Identifying iatrogenic triggers is crucial for diagnosing acute changes in hospitalized patients.
2
Interpret the physical examination findings.
The patient has elevated jugular venous pressure, an S3 gallop, bibasilar crackles, and peripheral edema, which are all classic signs of acute decompensated heart failure.
Physical exam findings reliably differentiate between cardiogenic and primary pulmonary causes of dyspnea.
3
Reconcile the wheezing with the diagnosis of heart failure.
The wheezing is identified as 'cardiac asthma,' caused by peribronchial interstitial edema secondary to elevated left ventricular filling pressures.
Wheezing in a patient with a smoking history can be misleading, but the cardiac exam (S3) and volume status (JVP) dictate the true etiology.
4
Determine the most appropriate immediate intervention.
Intravenous furosemide is selected to promote diuresis and rapidly decrease preload.
Loop diuretics provide symptomatic relief in acute decompensated heart failure by reducing hydrostatic pressure in the pulmonary capillaries.

Key Concept

Diagnosis and management of acute decompensated heart failure presenting as cardiac asthma
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Topics

Cardiovascular System

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