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70 yr ol m is adm to the hosp wth chest pain of 8h dur.ECG demos ant ST elevation, fr whch he is gven tissue plasminogen activator,heparin, iv ntg. His symptoms resolve, and serum chem reveal peak cpk of 1400 and ck mb of 80. he is eventually started on oral meds and transferred outa the iccu. hs subsequent hosp course is uneventful until day 4 when he develops severe shortness of breath. bp 110/70,pr is 120. ex reveals a new systolic murmer. the mst appr ther interven wld be
a.emergent surgical consult and transfer to OR
b.iv heparin
c.iv hep and streptokinase
d.iv hep and furosemide
e.iv sodium nitroprusside.
This q troubled me a lot. I knw the answer but i want a good explanation.not just a guess.
chill
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I think the answer is E.
it is rupture ot the papillary muscle / interventricular septum -depending where you hear the murmur. Treatment - nitroprusside (reduces afterload and left ventricular wall stress) , inta-aortic balloon counterpulsation and anyway surgical correction is mandatory.
D
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it definitely does seem like Papillary Muscle injury.
Dia: would you not proceed straight to surgery (A)? is Nitroprusside definitely the first
mode of therapy? His blood pressure is already low, and i'm not sure if a lower BP
would be desired.
cheers
revo
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yeah keep going at it...i banged my head trying to figure out y the treatment is what it is.
answers in the evening.....
chill
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revo,
as far as I know mortality rates with early surgery are high (15-100% depending on clinical status and residual ventr function) so it is recommended just in patients remaining hemod instable or requiring continuous parental tx.
But, you may be right and surgery could be the most appropriate.
Simon???
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This poor old has acute pulmonary edema due to papillary muscle rupture 2ndary to whatever .... What to do is to use furosemide 1st + others you want to add.
My answer is DDDDDDDDDDDDDDDDDD
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Dia,
oh, actually i think you're right about Nitro. his pulse is HIGH, with a BP of 110/70. So
reducing afterload is IMPORTANT i think.
I think Surgery is reserved for if meds don't work.
i agree with Dia.....i'd to Nitroprusside (E) as well
cheers
revo
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hi,
Dia has got both the answer and the explanation right. I had chosen emergent surgery as the answer which turned out to be wrong. I have looked it up but was unable to find this explanation or the answer. Like revo I was of the opinion that vasodilators in a low BP scenario would be a bad idea. Obviously that was wrong thinking.
Hey Dia can u tell us which source u followed for the management of post mi complications????
chill
