kaps infinity - showman

[ArchivalUser]

A 61-year-old woman is status post a right total hip replacement 3 hours ago. She underwent an
uneventful replacement with hardware under spinal anesthesia. She is brought the postanesthesia care
unit (PACU) sedated but alert and oriented to person, place, and time. Her past medical history is
significant only for hypertension and gout for which she takes allopurinol and atenolol daily. On arrival to
the PACU, she complains of some mild shortness of breath and chest pain. Over the past 3 hours, her
shortness of breath significantly worsens and she has pleuritic chest pain on her right side. Her
temperature is 37.0 C (98.6 F), blood pressure is 100/60 mm Hg, pulse is 128/min, and respirations
are 32/min. She appears markedly dyspneic, but is alert and oriented to person, place, and time.
Physical examination is remarkable for clear lung fields and jugular venous pulse visible at 12cm with
the patient at 30 degrees elevation. There is no chest wall tenderness on palpation. The most
appropriate immediate action is to


A. administer a propranolol, intravenously

B. administer morphine for pain control

C. give the patient supplemental oxygen by face mask

D. order a chest radiograph

E. start warfarin therapy

[ArchivalUser]

c or d

will go for ccccccc!!!

hi showman and kaps and guest!!!

[ArchivalUser]

dd

[ArchivalUser]

dddd dyspnea hypotension wit cvp rased

thank u

[ArchivalUser]

ccc

[ArchivalUser]

c..

[ArchivalUser]

The correct answer is C. If a transesophageal echo probe is placed in every patient undergoing
hip-fracture repair, the incidence of fat and particle debris in the right atrium approaches 70%. In fact,
a major risk of lower extremity orthopedic procedures is pulmonary embolism due to fat or clot. The
intramedullary pressures generated during the repair are greater than 500psi and are enough to
cause venous extrusion of fat and other particulate matter into the circulation. This patient almost
certainly suffered a fat embolism and her hypotension, elevated neck veins, tachycardia, and dyspnea
reflect this fact. She requires supplemental oxygen and possibly endotracheal intubation since this
syndrome will slowly progress over the ensuing 24 hours.

Giving the patient propranolol (choice A) for her tachycardia could be fatal . Her tachycardia is a
response to the low filling of the left ventricle secondary to fat embolism present in her pulmonary
arterioles and venules. Her blood pressure is already tenuous despite her tachycardia and without it
her cardiac output and therefore blood pressure would likely drop precipitously. There is no evidence
that this patient has rate-related cardiac ischemia and therefore is hypotensive.

Giving the patient morphine for pain control (choice B) is not appropriate. The patient is not
complaining of surgical site pain, but rather she is manifesting pain from a pleuritic component of her
embolism. Treating this pain with morphine before the patient is stabilized would result in respiratory
collapse since the morphine would depress her respiratory rate and therefore her oxygenation.

Ordering a chest radiograph (choice D) is appropriate to evaluate for any pulmonary edema or
obvious pulmonary infarction only after the patient has received oxygen. Patients should be treated
and stabilized prior to diagnostic interventions.

Warfarin therapy (choice E) is incorrect in this case because this patient did not suffer a pulmonary
embolism due to clot, but from fat. Clot emboli are an important source of morbidity and mortality in
this population, but usually beginning 24 hours post-procedure. This patient has had an acute
perioperative event that is too soon to be clot.

[ArchivalUser]

hi stefan...nice qs

[ArchivalUser]

thx showman..!

[ArchivalUser]

good questions showman
thanks