q1 (part 7) - harry206

[ArchivalUser]

PLZ READ Q1 (PART 6) BEFORE READING THIS Q

The patient™s pain recurs again in the ED. You suspect
that the patient is having a myocardial infarction but
do not yet have unequivocal proof (such as ECG
changes). The patient becomes markedly hypotensive
in response to SL nitroglycerin.
Which of the following is true?


A) Further nitroglycerin is contraindicated in this
patient.
B) Hypotension caused by nitroglycerin is usually
unresponsive to IV saline.
C) Hypotension caused by nitroglycerin may be
indicative of a right ventricular infarction, which
is most commonly associated with an inferior
wall MI.
D) Hypotension caused by nitroglycerin is diagnostic
of cardiogenic shock, suggesting that this patient
will have a poor outcome.
E) Since this patient is hypotensive, her interests are
best served by ordering a cardiology consult and
immediate intervention in the cath lab

[ArchivalUser]

aa

[ArchivalUser]

cc.

[ArchivalUser]

The correct answer is C. Hypotension in response to
nitroglycerin may be indicative of a right ventricular
infarct, which is most commonly associated with an
inferior wall MI. Since the right ventricle is dependent
on filling pressure, NTG, which drops the preload,
will frequently result in hypotension in those
with a right ventricular infarct. Answer A is incorrect
because hypotension from SL nitroglycerin is not a
contraindication to additional nitrates once the patient™s
blood pressure is stable. A typical SL dose is
400 micrograms (0.4 mg). A typical IV dose starts at
20 micrograms per minute. Thus, the SL dose is quite a bit larger than the IV dose. In such a situation, you
could consider starting IV nitroglycerin at 10“20
micrograms per minute and titrating up as the blood
pressure allows. Answer B is incorrect because hypotension
from NTG is usually responsive to a saline
bolus. Answer D is incorrect because hypotension from
NTG does not indicate cardiogenic shock. Certainly
patients with cardiogenic shock will be hypotensive,
but hypotension from NTG does not define cardiogenic
shock. Answer E is incorrect as well. Patients
with an MI may need to go to the cath lab quickly, especially
if they are hypotensive. However, this patient
may or may not have a myocardial infarction and the
blood pressure will likely recover.