Examkin

Soru

Zorluk: ZorCardiovascular System

A 68-year-old woman is brought to the emergency department by her family due to sudden-onset, severe shortness of breath that awoke her from sleep 2 hours ago. She reports feeling as though she is "drowning" and has a prominent cough producing frothy sputum. Her medical history is significant for long-standing bronchial asthma, poorly controlled essential hypertension, and osteoarthritis. Current medications include inhaled budesonide-formoterol, amlodipine, and diclofenac. Upon arrival, her blood pressure is 225/120 mm Hg, heart rate is 118/min, respiratory rate is 32/min, and oxygen saturation is 84% on room air. The patient is diaphoretic, sitting bolt upright, and using accessory muscles of respiration. Lung auscultation reveals diffuse, loud expiratory wheezing bilaterally with faint crackles at the lung bases. Cardiac examination is notable for regular tachycardia and an S4 gallop; an S3 gallop is not appreciated due to the loud breath sounds. A bedside point-of-care ultrasound reveals bilateral B-lines in all lung zones. Electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy. Which of the following is the most appropriate initial pharmacological therapy for this patient?

  1. Intravenous nitroglycerinCevap
  2. B
    Intravenous methylprednisolone
  3. C
    Intravenous labetalol
  4. D
    Continuous nebulized albuterol
  5. E
    Intravenous levofloxacin

Cevap

The correct answer is intravenous nitroglycerin.
The correct answer is intravenous nitroglycerin. This patient's presentation is highly consistent with acute decompensated heart failure (ADHF) precipitating flash pulmonary edema, specifically characterized as sympathetic crashing acute pulmonary edema (SCAPE). Her extreme hypertension results in severely elevated afterload, which acutely impairs left ventricular forward flow and causes rapid fluid accumulation in the pulmonary alveoli and interstitium. The diffuse wheezing is a classic presentation of 'cardiac asthma', where peribronchial edema leads to airway narrowing, mimicking a primary asthma exacerbation. The presence of frothy sputum and bilateral B-lines on bedside ultrasound definitively points toward pulmonary edema rather than simple bronchospasm. Her recent use of diclofenac, an NSAID, likely contributed to fluid retention and worsening hypertension. The most appropriate initial pharmacological therapy is rapid afterload and preload reduction with intravenous vasodilators, such as nitroglycerin, often combined with non-invasive positive pressure ventilation (NIPPV).

Adım Adım Çözüm

1
Analyze the patient's presentation and vital signs.
The patient has abrupt-onset severe dyspnea, extreme hypertension (225/120 mm Hg), hypoxia, frothy sputum, and diaphoresis.
Identifying these classic signs is critical to recognize a hypertensive emergency presenting as sympathetic crashing acute pulmonary edema.
2
Integrate physical examination and diagnostic findings.
Despite a history of asthma and the presence of diffuse wheezing, the B-lines on lung ultrasound and frothy sputum confirm the presence of extravascular lung water.
This differentiates primary respiratory failure (asthma exacerbation) from cardiogenic pulmonary edema, where peribronchial edema causes airway compression and secondary wheezing ('cardiac asthma').
3
Determine the most appropriate initial pharmacological therapy.
Intravenous nitroglycerin is selected to rapidly decrease both preload and afterload.
Rapid vasodilation relieves the extreme afterload on the failing left ventricle, shifting fluid out of the pulmonary circulation. Beta-blockers must be avoided due to negative inotropy.

Anahtar Kavram

Management of acute decompensated heart failure presenting as sympathetic crashing acute pulmonary edema (SCAPE).
Bu soruyu puanla

Konular

Cardiovascular System

Bu konudan daha fazla soru