View source for WBR0924

 {{WBRQuestion
|QuestionAuthor=[[MM]]
|ExamType=USMLE Step 3
|MainCategory=Emergency Room
|SubCategory=Cardiovascular
|MainCategory=Emergency Room
|SubCategory=Cardiovascular
|MainCategory=Emergency Room
|SubCategory=Cardiovascular
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Cardiovascular
|MainCategory=Emergency Room
|SubCategory=Cardiovascular
|MainCategory=Emergency Room
|SubCategory=Cardiovascular
|MainCategory=Emergency Room
|SubCategory=Cardiovascular
|MainCategory=Emergency Room
|MainCategory=Emergency Room
|SubCategory=Cardiovascular
|Prompt=A 62 year-old man comes to ED complaining of acute shortness of breath, fatigue, and worsening exertional dyspnea.  He hardly can talk, and mentioned waking up several times at night on sever cough with frothy sputum.  He used to sleep on two pillows but now he is using three.  The patient has past medical history of hypertension for 15 years, and diabetes mellitus for 20 years.   On examination, his BP 90/70, pulse 120, respiratory rate 28, and temperature is 36.9 C (98.5F). Chest examination revealed decreased breath sounds and dullness at both bases with bibasilar rales.  Cardiac examination revealed diffuse, laterally and inferiorly displaced apex, with distant heart sounds and S3 gallop.  There is a jugular venous distention, with JVP of 12 cm, and oxygen saturation of 83%.  Extremities are cool and show 2+ pitting edema in both legs up to the knee.  After he is been admitted to ICU, and being on Oxygen, furosemide, nitrates, and morphine, his oxygen saturation is not improving, and you notice no improvement in his case, which of the following is the best next step in his management?
|Explanation=Acute management with a positive inotrope will be necessary in the cases that don’t respond to preload reduction alone to control the acute symptoms.  Dobutamine is drug of choice used as further management of acute pulmonary edema cases after the clock is moved forward 30–60 minutes and there is no response to preload reduction.
Mechanical ventilation maximizes myocardial oxygen delivery and ventilation, and should be used when the inotrope fail to improve the case, and oxygen saturation is not improving.  Positive end-expiratory pressure is generally recommended to increase alveolar patency and to enhance oxygen delivery and carbon dioxide exchange.
Related to [[WBR0996]]
|AnswerA=I.V Diltiazem  drip
|AnswerAExp=Incorrect
Calcium channel blockers such as diltiazem should be avoided in patients with impaired left ventricular function due to negative inotropic effects.
|AnswerB=I.V Dobutamine
|AnswerBExp=Correct
Dobutamine is drug of choice used as further management of acute pulmonary edema cases after the clock is moved forward 30–60 minutes and there is no response to preload reduction.
|AnswerC=Metoprolol
|AnswerCExp=Incorrect
Metoprolol use in acute decompensated heart failure is suspected as they may induce hypotension and further cardiogenic shock.
|AnswerD=Digoxin
|AnswerDExp=Incorrect
Digoxin is never the right answer as an acute treatment for pulmonary edema
|AnswerE=Mechanical ventilation
|AnswerEExp=Incorrect
Mechanical ventilation maximizes myocardial oxygen delivery and ventilation, and should be used when the inotropes fail to improve the case, and oxygen saturation is not improving.  Positive end-expiratory pressure is generally recommended to increase alveolar patency and to enhance oxygen delivery and carbon dioxide exchange.
|RightAnswer=B
|WBRKeyword=[[Pulmonary edema]]
|Approved=No
}}