WBR1028

Author	[[PageAuthor::Ayokunle Olubaniyi, M.B,B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 60-year-old Caucasian male with a past medical history of hypertension and coronary artery disease was brought to the emergency department (ED) a few hours after he developed sudden, severely worsening chest pain and shortness of breath. The pain was stabbing, radiating to the back and was associated with nausea and profuse sweating. He confessed he has not been compliant on his antihypertensive medication for the past two months. At presentation his vitals are: temperature is 39.2°C, pulse 110 beats per minute, respiratory rate 32/min, and blood pressure 90/70 mmHg. On examination his neck veins are distended. Lungs are clear bilaterally. Cardiovascular examination reveals muffled heart sounds. Abdomen is tender to palpation, especially in the epigastrium with associated guarding, and the extremities are cold to touch. Laboratory results reveal normal parameters. Electrocardiogram showed sinus tachycardia but no acute ischemic changes. Chest x-ray and transesophageal echocardiogram reveal enlarged cardiac silhouette and right atrial and ventricular collapse, respectively. Resuscitative measures were initiated. What is the next best step in the management of this patient?]]
Answer A	AnswerA::Pericardiocentesis
Answer A Explanation	AnswerAExp::This is indicated for all cases of cardiac tamponade except aortic dissection or myocardial rupture.
Answer B	AnswerB::Pericardiocentesis in preparation for open surgical repair
Answer B Explanation	AnswerBExp::This is usually done for symptomatic relief in preparation for surgical repair.
Answer C	AnswerC::Open surgical repair
Answer C Explanation	AnswerCExp::This is the treatment of choice for aortic dissection, but Pericardiocentesis provides a more rapid and urgent symptomatic relief to this patient.
Answer D	AnswerD::Administer diuretics in preparation for pericardiocentesis
Answer D Explanation	AnswerDExp::Administration of diuretics is generally avoided to prevent worsening of the central venous pressure.
Answer E	AnswerE::Initiate positive pressure ventilation in preparation for pericardiocentesis
Answer E Explanation	AnswerEExp::Positive pressure ventilation reduces the cardiac filling, and it is generally avoided in this category of patients
Right Answer	RightAnswer::B
Explanation	[[Explanation::This is a case of aortic dissection complicated by cardiac tamponade. The triad of hypotension, tachycardia and muffled (distant) heart sound, referred to as Beck’s triad, makes cardiac tamponade a high differential. Cases of cardiac tamponade caused by aortic dissection or rupture often requires urgent open surgical repair. Pericardiocentesis is advised prior to repair for immediate symptomatic relief. Educational Objective: Always suspect cardiac tamponade whenever you observe a triad of hypotension, tachycardia and muffled (distant) heart sound, referred to as Beck’s triad. Pericardiocentesis is done to provide immediate symptomatic relief to the patient in preparation for the surgical repair. Reference: http://www.wikidoc.org/index.php/Cardiac_tamponade_resident_survival_guide Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::Pericardiocentesis, WBRKeyword::Cardiac tamponade
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::