12-26-2008, 06:06 PM
A 69-year-old man was treated 3 hours ago with alteplase for an acute ST-elevation myocardial infarction involving leads II, III, and aVF after presenting with 30 minutes of severe substernal chest pain associated with nausea and diaphoresis. His chest pain resolved 15 minutes after initiation of treatment. He denied preceding chest pain up until today's presentation. His treatment medications given on admission included aspirin, intravenous metoprolol, and an unfractionated heparin drip.
He had been hemodynamically stable, but developed a progressive decline in systolic blood pressure from 120 mm Hg to 74 mm Hg. He now complains of lightheadedness but denies dyspnea. Physical examination shows a heart rate of 64/min, pulsus paradoxus of 6 mm Hg, clear lung fields, jugular venous distention, and diminished heart sounds with a grade 1/6 early systolic murmur at the right upper sternal border. The abdomen is benign and the extremities cool.
Which immediate empiric treatment is the best choice in this patient?
A Volume challenge with intravenous saline
B Dopamine
C Alteplase
D Transcutaneous pacing
E Intra-aortic balloon pump counterpulsation
He had been hemodynamically stable, but developed a progressive decline in systolic blood pressure from 120 mm Hg to 74 mm Hg. He now complains of lightheadedness but denies dyspnea. Physical examination shows a heart rate of 64/min, pulsus paradoxus of 6 mm Hg, clear lung fields, jugular venous distention, and diminished heart sounds with a grade 1/6 early systolic murmur at the right upper sternal border. The abdomen is benign and the extremities cool.
Which immediate empiric treatment is the best choice in this patient?
A Volume challenge with intravenous saline
B Dopamine
C Alteplase
D Transcutaneous pacing
E Intra-aortic balloon pump counterpulsation