A 54-year-old woman arrives at the emergency department with severe, sudden-onset breathin… — USMLE Step 2 CK

A $54$ -year-old woman arrives at the emergency department with severe, sudden-onset breathing difficulty that started one hour ago. The patient has a history of long-standing hypertension but has not taken her prescribed medications for several months.

On evaluation, she is sitting upright, diaphoretic, and in significant respiratory distress.

Vital signs show a temperature of $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure of $220/115\text{ mm Hg}$ , heart rate of $118/\text{min}$ , and respiratory rate of $28/\text{min}$ . Oxygen saturation is $88\%$ on room air.

Physical examination reveals prominent jugular venous distention. Pulmonary auscultation demonstrates bilateral crackles extending to the apices and widespread expiratory wheezing.

Cardiac auscultation reveals a regular tachycardia and a prominent fourth heart sound (S4). There is no peripheral edema.

Which of the following is the most appropriate next step in the management of this patient?

Intravenous furosemide and nitroglycerinAnswer
B
Inhaled albuterol and systemic glucocorticoids
C
Intravenous piperacillin-tazobactam
D
Intravenous sodium bicarbonate
E
Contrast-enhanced computed tomography of the chest

Answer

Intravenous furosemide and nitroglycerin

The correct answer provides rapid preload and afterload reduction. The patient's clinical presentation—severe hypertension, hypoxia, diffuse crackles, jugular venous distention, and an S4 gallop—is classic for acute decompensated heart failure presenting as flash pulmonary edema. The rapid rise in blood pressure severely increases left ventricular afterload, leading to acute left ventricular failure and fluid back-up into the pulmonary vasculature. The most appropriate initial management involves prompt blood pressure control and volume offloading with intravenous nitroglycerin and a loop diuretic such as furosemide.

Step-by-Step Solution

Identify the primary clinical syndrome.

The patient has severe hypertension, hypoxia, jugular venous distention, S4 gallop, and diffuse crackles, indicating acute decompensated heart failure presenting as flash pulmonary edema.

Recognizing the syndrome rapidly limits the differential diagnosis and dictates immediate, life-saving management.

Determine the optimal acute pharmacological intervention.

Select agents that rapidly reduce both preload and afterload.

Intravenous nitroglycerin quickly lowers blood pressure (afterload) and venous return (preload), while an intravenous loop diuretic removes excess fluid volume.

Key Concept

Flash pulmonary edema in the setting of hypertensive emergency requires rapid preload and afterload reduction, typically with intravenous nitroglycerin and a loop diuretic.

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