Approach to Patients with Hemodynamic Compromise

Approach to Patients with Hemodynamic Compromise

Order 5898221

Approach to Patients with Hemodynamic Compromise

1 A 68-year-old woman with a past history of wellcontrolled hypertension presents to the hospital with
several days of intermittent substernal chest pressure
and shortness of breath. On arrival to the emergency
room, her blood pressure is 90/70 mm Hg, her heart
rate is 105 beats per minute, and her respiratory rate
is 26 breaths per minute. She is diaphoretic and in
visible respiratory distress. Cardiovascular examination is notable for a jugular venous pressure of 8 cm,
bibasilar rales at the bases, and a 3/6 harsh systolic
murmur at the left sternal border. Her extremities are
cool. Her electrocardiogram reveals sinus tachycardia
with 2 mm ST-segment elevation in V1 through V4
and 1 mm ST-segment depression in II, III, and aVF.
Her baseline complete blood count (CBC), serum
electrolytes, and renal function are normal.
She is given aspirin and heparin and undergoes
endotracheal intubation for airway support. She is
taken to the cardiac catheterization laboratory for
emergent angiography. Single-frame cineangiogram
in the left anterior oblique (LAO)-cranial projection
of her left coronary and left ventricular angiogram
are shown in the following figures. The next most
appropriate course of action would be:
(A) Administration of abciximab followed by primary percutaneous coronary intervention (PCI)
of the left anterior descending (LAD) artery
(B) Insertion of an intra-aortic balloon pump
(IABP) followed by primary PCI of the LAD
(C) Primary PCI of the LAD and referral for
emergency coronary artery bypass surgery
(D) Insertion of IABP and referral for emergent
coronary artery bypass surgery
2 A 36-year-old man undergoes diagnostic coronary
and left ventricular angiography for evaluation of
chest pain. His cardiac examination is notable for
the presence of a mid-peaking systolic ejection murmur, heard best at the left sternal border without
radiation. His lungs are clear to auscultation. His
electrocardiogram shows left ventricular hypertrophy with secondary repolarization abnormalities. His
coronary angiogram demonstrates normal left and
right coronary arteries, and left ventricular angiography reveals normal systolic function. A simultaneous
left ventricular and femoral arterial pressure tracing
is shown in the following figure.
202

Approach to Patients with Hemodynamic Compromise

Approach to Patients with Hemodynamic Compromise 203
The procedure was uneventful, but during recovery, the patient complains of chest pain and
lightheadedness. On physical examination, his blood
pressure is 70/50 mm Hg with a heart rate of 88
beats per minute. He appears diaphoretic and the
extremities are cool. In addition to administration
of intravenous fluids, which of the following should
be administered?
(A) Dobutamine
(B) Dopamine
(C) Phenylephrine
(D) Atropine
3 An 80-year-old woman presents to a community hospital with unstable angina associated with transient
inferolateral ST-segment depression. She is treated
with aspirin, clopidogrel, enoxaparin, and eptifibatide, in addition to metoprolol and atorvastatin.
She is stabilized and subsequently ‘‘rules in’’ for a
myocardial infarction (MI) with a cardiac troponin
I of 2.1 ng per mL. Her CBC, serum electrolytes,
and renal function are normal. She undergoes diagnostic coronary and left ventricular angiography,
which reveal normal left ventricular systolic function and single vessel coronary artery disease with a
90% stenosis in the mid right coronary artery. She is
transferred to a tertiary hospital where she undergoes
placement of a drug-eluting stent with an excellent
angiographic result. The femoral arteriotomy site is
closed using a collagen plug closure device.
Two hours later, she complains of nausea,
abdominal pain, and vague chest discomfort. Her
blood pressure is 90/60 mm Hg and heart rate is 44
beats per minute. She appears pale and diaphoretic.
Her lungs are clear to auscultation and her cardiac
examination is without murmurs, rubs, or gallops.
Her abdomen is soft with no reproducible tenderness.
Her right groin has a small hematoma with no
evidence of bleeding. Her electrocardiogram shows
nonspecific findings.
Following administration of 0.5-mg atropine
intravenously and normal saline, her blood pressure
and heart rate rise to 108/68 mm Hg and 70 beats per
minute, respectively. Which of the following should
be done next?
(A) Continued observation
(B) Urgent coronary angiography to exclude acute
stent thrombosis
(C) Discontinue eptifibatide and obtain stat CBC
and type and crossmatch
(D) Computed tomography (CT) of the abdomen
4 Which of the following is not a contraindication to
IABP insertion?

Approach to Patients with Hemodynamic Compromise

(A) Severe peripheral arterial disease
(B) Aortic insufficiency
(C) Recent fibrinolytic therapy
(D) Abdominal aortic aneurysm
5 A 66-year-old woman with a history of hypertension
and hyperlipidemia undergoes diagnostic coronary
angiography for an abnormal exercise stress test.
The patient receives standard premedication for the
procedure, including midazolam and fentanyl. The
catheter is advanced smoothly around the aortic arch
and the left main coronary is engaged. A sample of
her initial left coronary angiogram is shown in the
following figure.
The patient suddenly complains of shortness
of breath and chest pain. Physical examination is
notable for a blood pressure of 82/50 mm Hg, heart
rate of 94 beats per minute, respiratory rate of 24
breaths per minute, and oxygen saturation of 92%.
Cardiac examination reveals no murmurs or gallops
and her lungs demonstrate diffuse inspiratory and
expiratory wheezing. Which of the following should
be done next?
(A) Switch to a lower osmolar iodinated contrast
agent
(B) Repeat left coronary angiography to exclude
dissection of the left main coronary artery
(C) Administer diphenhydramine, antihistamines,
and epinephrine
(D) Administer flumazenil to reverse the effects of
the benzodiazepine
204 900 Questions: An Interventional Cardiology Board Review
6 A 63-year-old man is admitted to the hospital for
evaluation of exertional shortness of breath and chest
pain. His risk factors for ischemic heart disease include hypertension, hyperlipidemia, and obesity. His
initial treatment includes aspirin and unfractionated heparin. Cardiac enzymes are negative for MI,
and the remainder of his laboratory values is normal. A pharmacologic nuclear study is performed
and demonstrates a medium-sized moderately severe perfusion defect in the inferolateral wall with
near-complete reperfusion on the resting images. He
presents to the cardiac catheterization laboratory for
diagnostic right and left heart catheterization through
the transfemoral approach. Using a balloon-tipped
flotation catheter, right-sided pressures are recorded
as follows: Right atrial (RA) pressure (mean, mm
Hg) 11; right ventricular (RV) pressure (systolic, end
diastolic, mm Hg) 52/10; and pulmonary arterial
(PA) pressure (systolic, diastolic, mean, mm Hg)
54/20, 31.
The catheter is advanced into the left-sided pulmonary wedge position and the mean pressure is
18 mm Hg. Following deflation of the balloon, an
appropriate rise in the mean pressure is seen, confirming that the catheter was in the wedge position.
The patient suddenly develops hemoptysis with rapid
oxygen desaturation. The most appropriate immediate management includes:
(A) Placement of the patient in the left lateral
decubitus position and emergency thoracic
surgical consultation for presumed rupture of
the pulmonary artery
(B) Reinflation of the balloon-tipped catheter in
the pulmonary artery for presumed rupture of
the pulmonary artery
(C) Administration of protamine
(D) Surgical consultation for emergency chest tube
insertion

Having a hard time figuring out how to do your assignment?

Ask our experts for help and get it done in no time!