This is meant to elicit more thinking, so feel free to respond whenever.
The vitals and your clinical exam/abbreviated history should guide your decision-making here. If the patient is "clinically euvolemic", why are you going down the path of getting fluid off of them?
Why morphine? I would not give this patient morphine. The only people in respiratory distress that I would give morphine to are comfort care patients with air hunger.
Goes back to what I previously said. If the patient's clinically euvolemic, it doesn't make sense to give diuretics. If the patient is genuinely in flash pulm edema, IV 40 of Lasix isn't that huge of a dose. Regardless of whether or not they're Lasix-naive, I'd give them 160 IV and deal with the kidneys later. Regardless, the most important thing you can do for this patient after giving Lasix is checking to make sure they're actually producing urine.
Sure, you can call an RRT. No one will ever fault you for calling for help too early. Apart from the tachypnea, what makes you worried this guy's going to decompensate in front of you? If you're going into IM, you'll frequently be called to bedside for dyspneic patients who are satting (briefly) in the mid-to-upper 80s. As you gain experience, you'll get a better sense of when to call for help early and when you know you have time to figure things out.
NTG is fair if you genuinely think someone's flashing on you (though I wouldn't start it as a drip when the SL gives a whopping 400 mcg dose right off the bat -- assuming they don't have critical AS or pulm HTN or RV dysfunction).
The problem here is that you're worried about this guy maybe having submassive vs. massive PE and RV dysfunction. What's your rationale for dropping the preload on a failing right heart?
Several questions here:
1. How does an EKG tell you someone's having a "hypertensive exacerbation"?
2. IV ACEi? Why'd you pick that one? There are far, far better go-to's for IV drips in the case of HTN emergency. I cannot imagine a single scenario where I'm choosing IV ACEi. Not only that, even if you really wanted to, good luck convincing the pharmacy to let you use that.
Depends where you're training.
Awesome. Thank you for this. I don't need much time to respond. Point by point.
1. My mistake. I meant
not clinically
hypovolemic. Clearly he's hypervolemic +11 L with a wet chest. Was posting on my phone.
2. Morphine has some evidence for preload reduction, but mostly it reduces anxiety associated with dyspnea. It's the standard cock-tail for acute decompensated HF, but I looked into it, and its use turns out to be an independent predictor of mortality and intubation from the ADHERE registry. It's also associated with increased RV filling pressure and negative inotropy. For me,
morphine seems out for acute decompensated heart failure. If I really need anxiolysis, I'd rather reach for a small dose benzo, which doesn't seem to have the same haemodynamic consequences. Thank you for making me look into this. And acute decompensated heart failure is just one of my differentials pending CXR, ABG, EKG, etc.
3. I'm worried that he might deteriorate because OP specifically asked, "what if he fails supplemental oxygen"? Need to move on to 10 mg Hg CPAP and anticipate for failure. My differentials includes submassive PE, ARDS, or septic cardiomyopathy (in addition to acute decompensated HF)--happy to trial NIV, but "intubate early" is not an unreasonable thought. Watch for excessive WOB or AMS closely and let someone know earlier rather than later.
4. I'm dropping preload on a guy + 11 L, SBP > 120, and a wet chest with a GTN spray. What's the cost/benefit here? Dropping preload on a failing ventricle is not a bad thing, since it often repositions you on the Frank-Starling curve. This is the same rationale that's new being convincingly argued to run septic patients dry. It's also consistent with the evidence on acute decompensated HF, which is high on the differentials.
5. My point was to pay close attention for any
cardiac etiologies that might change management. But LVH and evidence of old infarcts on EKG suggests structural cardiac lesions consistent with hypertensive exacerbation of underlying CHF (and of course you look at the BP and physical exam).
6. One off IV ACE-i actually has great evidence for this clinical situation, even though it's not a common practice. Key is after-load reduction. I think both furosemide and enalapril are worth pushing if hypertensive.
7. Really? The intern is pushing therapeutic anticoagulation on this patient before getting a CTA? Okay. Are you throwing on thrombolytics? Do you feel confident interpreting MOPETT vs TOPCAT vs PEITHO vs ULTIMA? I don't.
Some decisions are okay for an intern to make.
Some I would want a resident's input (that just might be my hospital though). And I'm still not convinced this is a PE, but since it's really high on my differentials... would you push anticoagulation?
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