Multiprofessional Critical Care Review: Adult 2024 (MCCRCA24ON)-Question and Answer Session 3

Question and Answer Session 3

Pdf Summary

A 49-year-old man presents to the emergency department with chest pain and diaphoresis. He is diagnosed with a non-ST elevation myocardial infarction. In addition to aspirin, clopidogrel, and enoxaparin, the most appropriate medication to administer within the next 24 hours would be metoprolol.<br /><br />A 56-year-old man is admitted to the ICU with hypoxemic respiratory failure. On physical examination, he has diffuse lung rales, elevated jugular venous pressure, and a short early systolic murmur heard at the apex. The most appropriate next diagnostic test would be transesophageal echocardiography to evaluate for acute papillary muscle rupture as a complication of subacute myocardial infarction.<br /><br />A 75-year-old man presents to the emergency department with acute chest pain that radiates to the back. Chest CT is negative for pulmonary embolus but there is evidence of an intimal flap in the descending thoracic aorta. The most appropriate initial management would be medical management to achieve a heart rate less than 60 beats/min and systolic blood pressure 100-120 mm Hg, as he has a type B aortic dissection.<br /><br />A 55-year-old patient is admitted to the ICU with dyspnea on exertion and orthopnea. Physical examination reveals a pansystolic murmur, lung sounds are clear, and serum electrolyte panel shows ionized calcium 5.2 mg/dL. The most likely diagnosis is tricuspid regurgitation.<br /><br />A patient with an acute myocardial infarction has received IV beta-blockers and aspirin. He has a blood pressure of 85/60 mm Hg and the pulse oximeter is no longer tracking well. The most favorable long-term outcome would be achieved with rapid cardiac catheterization, which provides the best chance of improved outcomes in patients with acute ST-elevation myocardial infarction over and above other interventions.<br /><br />A 77-year-old man is admitted to the ICU in the late afternoon for observation after an uneventful revascularization of his right lower extremity. He requires intermittent labetalol and nitroprusside to maintain a systolic BP less than 160 mm Hg. He suddenly becomes dizzy and reports an irregular heartbeat. The most likely reason for the arrest is the administration of haloperidol, which has been associated with torsade de pointes.<br /><br />A 61-year-old man who was recently hospitalized for treatment of chronic obstructive pulmonary disease develops acute, severe chest pain and dyspnea. The ECG shows anterior lead ST elevations and troponin level is mildly elevated. This is most likely due to acute coronary syndrome due to severe stenosis of the left main coronary artery.<br /><br />A 65-year-old woman admitted for aneurysmal subarachnoid hemorrhage presents with dyspnea and substernal chest pain. ECG shows ventricular fibrillation, but her native cardiac function appears to be improving. The most appropriate immediate course of action is no intervention, as ventricular fibrillation has no impact on effective cardiac output in patients with biventricular assist devices.<br /><br />The intraaortic balloon pump pressure tracing shown is associated with early balloon inflation, which can result in premature closure of the aortic valve and other adverse effects.<br /><br />A 30-year-old man placed on peripheral venoarterial extracorporeal membrane oxygenation (ECMO) develops worsening oxygen saturations throughout the day. The most appropriate next step in management would be to consider changing to central venoarterial ECMO or increasing circuit flow, as the patient may be experiencing differential hypoxia.

Keywords

chest pain

myocardial infarction

metoprolol

respiratory failure

transesophageal echocardiography

aortic dissection

tricuspid regurgitation

acute coronary syndrome

ventricular fibrillation

extracorporeal membrane oxygenation

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