Examkin

Question

Difficulty: MediumInitial Stabilization and Triage

A 54-year-old man is brought to the emergency department due to sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. The pain started 45 minutes ago while he was moving heavy furniture. He has a history of essential hypertension and tobacco use. On presentation, he is anxious and diaphoretic. Vital signs are temperature 37.0°C (98.6°F), blood pressure 210/120 mmHg in the right arm and 170/100 mmHg in the left arm, heart rate 115/min, and respiratory rate 24/min. Pulse oximetry is 96% on room air. Neurologic examination is unremarkable. Electrocardiogram reveals sinus tachycardia with left ventricular hypertrophy but no acute ischemic changes. Which of the following is the most appropriate next step in the management of this patient?

  1. Administration of intravenous esmololAnswer
  2. B
    Computed tomography angiography of the chest
  3. C
    Administration of intravenous sodium nitroprusside
  4. D
    Administration of chewable aspirin and intravenous heparin
  5. E
    Urgent transesophageal echocardiography

Answer

The correct answer is the administration of intravenous esmolol.
In a patient with a highly suspected acute aortic dissection (tearing chest/back pain, asymmetric blood pressures), immediate medical management focuses on anti-impulse therapy to reduce aortic wall shear stress (dP/dt). Intravenous beta-blockers (such as esmolol or labetalol) are the first-line agents to rapidly lower both heart rate and blood pressure before sending the patient for definitive diagnostic imaging.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The patient has severe, tearing chest pain radiating to the back, severe hypertension, and asymmetric blood pressures in the upper extremities.
To form a primary working diagnosis of acute aortic dissection.
2
Determine the most critical initial management priority for the suspected diagnosis.
The immediate goal is anti-impulse therapy to reduce left ventricular contractility (dP/dt) and sheer stress on the aortic wall.
To prevent rapid propagation of the intimal tear, which can lead to fatal complications such as rupture or tamponade.
3
Select the appropriate pharmacologic agent for initial stabilization.
An intravenous beta-blocker, such as esmolol or labetalol, is selected to rapidly lower the heart rate (goal < 60/min) and blood pressure.
Beta-blockade must always precede vasodilation (e.g., nitroprusside) in this context to prevent reflex tachycardia.

Key Concept

Prioritizing anti-impulse therapy (beta-blockade) for hemodynamic stabilization in acute aortic dissection before proceeding with definitive diagnostic imaging.
Rate this question

Topics

Initial Stabilization and Triage

More questions from this topic