A rapid response team is called to the bedside of a 72-year-old woman who was admitted two… — USMLE Step 2 CK

A rapid response team is called to the bedside of a $72$ -year-old woman who was admitted two days ago for community-acquired pneumonia and a suspected exacerbation of chronic obstructive pulmonary disease (COPD). Her medical history includes tobacco use disorder, type 2 diabetes mellitus, and a prior anterior myocardial infarction. Initial management included intravenous ceftriaxone, azithromycin, inhaled bronchodilators, and systemic glucocorticoids. Sputum cultures obtained on admission are now growing *Streptococcus pneumoniae* that is susceptible to penicillin.

Over the past $4$ hours, the patient has developed sudden, severe respiratory distress. Her temperature is $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure is $182/104$ mm Hg, pulse is $115$ /min, and respirations are $28$ /min. Pulse oximetry shows $86\%$ on room air. Physical examination reveals jugular venous distention to $11$ cm H $_2$ O. Chest auscultation reveals prolonged expiration with diffuse bilateral wheezing. Cardiac auscultation shows a regular tachycardia without murmurs. Point-of-care ultrasound of the lungs demonstrates diffuse bilateral B-lines.

Laboratory studies show:
Serum sodium: $138$ mEq/L
Serum potassium: $4.2$ mEq/L
Serum chloride: $104$ mEq/L
Serum bicarbonate: $16$ mEq/L
Serum creatinine: $1.6$ mg/dL

Thyroid-stimulating hormone (TSH): $1.2$ mIU/L (N: $0.4 - 4.0$ mIU/L)
Free T4: $0.7$ ng/dL (N: $0.9 - 1.7$ ng/dL)

Arterial blood gas (room air):
pH: $7.30$
PaCO $_2$ : $32$ mm Hg
PaO $_2$ : $58$ mm Hg

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

Administer intravenous furosemideAnswer
B
Increase the frequency of inhaled albuterol
C
Switch antibiotic therapy to intravenous piperacillin-tazobactam
D
Administer intravenous levothyroxine
E
Administer intravenous sodium bicarbonate

Answer

Administer intravenous furosemide

The correct intervention is to administer an intravenous loop diuretic, such as furosemide. This patient is presenting with acute decompensated heart failure (ADHF), specifically manifesting as sympathetic crashing acute pulmonary edema (SCAPE). Despite her history of COPD and presentation with wheezing, the presence of severe hypertension, jugular venous distention, and diffuse bilateral B-lines on lung ultrasound strongly indicates cardiogenic pulmonary edema. Fluid accumulation around the bronchioles can cause airway narrowing, resulting in wheezing known as 'cardiac asthma.' The primary treatment involves rapid preload and afterload reduction using intravenous loop diuretics, vasodilators (e.g., nitroglycerin), and noninvasive positive pressure ventilation.

Step-by-Step Solution

Analyze the patient's acute respiratory distress in the context of her vital signs and physical examination.

The patient has severe hypertension (

182/104

mm Hg), jugular venous distention, wheezing, and diffuse bilateral B-lines on lung ultrasound.

These findings are classic for sympathetic crashing acute pulmonary edema (SCAPE) or acute decompensated heart failure (ADHF). The wheezing is 'cardiac asthma' due to peribronchial edema, not primary bronchospasm.

Determine the most appropriate initial management for hypertensive acute decompensated heart failure.

Intravenous loop diuretics (like furosemide) and vasodilators (like nitroglycerin), often combined with noninvasive positive pressure ventilation, are the treatments of choice.

These interventions rapidly reduce cardiac preload and afterload, relieving pulmonary congestion.

Evaluate the laboratory abnormalities to rule out other causes of decompensation.

The metabolic acidosis is fully compensated, the thyroid panel indicates euthyroid sick syndrome, and the sputum culture shows a narrow-spectrum susceptible pathogen.

Confirming these secondary findings ensures that distracting treatments (like bicarbonate, broad-spectrum antibiotics, or thyroid hormone) are avoided.

Key Concept

Patients with acute decompensated heart failure can present with severe wheezing ('cardiac asthma') and hypertension. Diagnosis is supported by signs of fluid overload (JVD) and pulmonary edema (B-lines on ultrasound); initial management involves preload reduction with intravenous loop diuretics and vasodilators.

Estimated Time:1m 30s

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