A 62-year-old woman comes to the emergency department due to a week of progressive shortness of breath and nonproductive cough. Since this morning, the patient has become more symptomatic as she is now unable to complete full sentences and says that she "can't breathe," especially when lying down. The patient was recently diagnosed with left breast cancer that was treated with a mastectomy followed by radiation and chemotherapy. She has no known history of heart or lung disease. Temperature is 37.2 C (99 F), blood pressure is 160/100 mm Hg, pulse is 130/min and irregular, and respirations are 30/min. The patient is sitting up at the edge of the bed, appears restless, and is using accessory muscles of respiration. Cardiac examination reveals an irregularly irregular tachycardia with normal heart sounds. Neck veins are distended. Bilateral crackles are heard on chest auscultation. This patient is most likely to benefit from which of the following interventions?

Question

A 62-year-old woman comes to the emergency department due to a week of progressive shortness of breath and nonproductive cough.  Since this morning, the patient has become more symptomatic as she is now unable to complete full sentences and says that she "can't breathe," especially when lying down.  The patient was recently diagnosed with left breast cancer that was treated with a mastectomy followed by radiation and chemotherapy.  She has no known history of heart or lung disease.  Temperature is 37.2 C (99 F), blood pressure is 160/100 mm Hg, pulse is 130/min and irregular, and respirations are 30/min.  The patient is sitting up at the edge of the bed, appears restless, and is using accessory muscles of respiration.  Cardiac examination reveals an irregularly irregular tachycardia with normal heart sounds.  Neck veins are distended.  Bilateral crackles are heard on chest auscultation.  This patient is most likely to benefit from which of the following interventions?

Quizplus · Accepted Answer

11ec25c8_d16f_bab0_bc81_49cd3a19544d_MD0003_00 This patient with dyspnea, orthopnea, distended jugular veins, and bibasilar crackles likely has acute decompensated heart failure (ADHF) from left ventricular systolic dysfunction due to the cardiotoxic effects of chemoradiation therapy. The initial management of ADHF in patients with normal or elevated blood pressure includes aggressive intravenous diuresis, oxygen supplementation, and possibly vasodilator therapy (eg, nitroglycerin, nitroprusside). In addition, early use of noninvasive ventilation in patients with hypoxemia and respiratory distress (such as this patient) provides rapid improvement in symptoms and reduces the need for mechanical intubation. (Choice A) Antibiotic therapy would be indicated in patients with suspected pneumonia as a cause of respiratory distress. Fever and productive cough are likely to be seen, but not distended neck veins or orthopnea. (Choice B) Inotropic medications (eg, dobutamine, milrinone) are occasionally used as adjunctive agents in patients with ADHF associated with hypoperfusion (eg, hypotension, end-organ dysfunction). Their routine use can be harmful due to increased myocardial oxygen demand and risk of arrhythmias. (Choice C) This patient has acute pulmonary edema (eg, crackles, respiratory distress) that requires aggressive diuresis and would be further exacerbated by intravenous fluid administration. Intravenous corticosteroids are indicated in patients with chronic obstructive pulmonary disease exacerbation, but this patient has no smoking history or wheezing. (Choice E) This patient may have developed atrial fibrillation (irregularly irregular rhythm) with rapid ventricular response (pulse >100/min) in the setting of ADHF and cardiotoxicity from chemoradiation therapy. Although oral anticoagulation should be considered for prevention of systemic thromboembolism in patients with atrial fibrillation, it is not the most appropriate immediate step in this patient with respiratory distress due to ADHF. (Choice F) Immediate pericardiocentesis is an invasive procedure indicated in patients with pericardial effusion with tamponade. Tamponade can cause dyspnea and jugular vein distension but would classically be associated with muffled heart sounds, pulsus paradoxus, and hypotension (rather than hypertension). A symptomatic pericardial effusion without tamponade physiology is unlikely to cause the profound ADHF manifestations seen in this patient. Educational objective: The initial therapy of patients with pulmonary edema and hypoxemia due to acute decompensated heart failure includes aggressive intravenous diuresis, oxygen supplementation, and possibly assisted ventilation. References: Acute decompensated heart failure update. (http://www.ncbi.nlm.nih.gov/pubmed/24251454) HFSA 2010 comprehensive heart failure practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/20610207) 2013 ACCF/AHA Guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/23741057)

A 62-Year-Old Woman Comes to the Emergency Department Due to a Week