smitha
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· A 63-year-old woman is admitted to the hospital after an acute inferior myocardial infarction. She is noted to be oliguric, and has a blood pressure of 80/55 mm Hg. A Swan-Ganz catheter is placed, revealing a diminished pulmonary capillary wedge of 4 mm Hg, normal pulmonary artery pressure of 22/4 mm Hg, and an increased mean right atrial pressure of 11 mm Hg. Which of the following is the most appropriate next step in management?
A. Balloon angioplasty
B. Digoxin
C. Fluids
D. Intraaortic balloon counterpulsation
E. Vasopressors
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| Nubie..
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Fluids...
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| smitha
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Purrrrrrrrfect  ...........cud u xplain wat's going on here in this pt. & y is fluids first appropriate step & not others???????
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| shirish_sss
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I GUESS SMITHA THIS PATIENT IS HAVING HYPOTENSION DUE TO HYPOVOLEMIA , SINCE THAT IS WHAT HIS PCWP REFLECTS.
HYPOVOLEMIA CAN BE ONE OF THE COMPLICATIONS OF ACUTE MI
CAUSES INCLUDE---
1) SEVERE VOMITTING ASSOCIATED WITH AMI AND CONSEQUENTLY REDUCED FLUID INTAKE OR
2) PREVIOUS VIGOROUS OR CURRENT DIURETIC THERAPY MOSTLY WITH FUROSEMIDE
FOR EARLY DIAGNOSIS WE HAVE TO DO SWANZ GANZ CATHETER STUDY AND MEASURE WHAT IS CALLED PULMONARY CAPILLARY WEDGE PRESSURE ( SWANZ-GANZ CATHETER IS INSERTED INTO INTERNAL JUGULAR VEIN ---SUPERIOR VENA CAVE---RIGHT ATRIUM---RIGHT VENTRICLE---PULMONARY ARTERY---PULMONARY CAPILLARY ----)
HERE IT IS WEDGED IN THE PILMONARY CAPILLARIES AND IT MESAURES THE LEFT HEART PRESSURE INDIRECTLY .
SINCE LEFT HEART IS THE ONE WHICH IS MOST COMMONLY AFFECTED IN ACUTE MI AND RESPONSIBLE FOR HYPOTENSION WE NEED TO KEEP THE LEFT HEART PRESSURE OPTIMUN AS MUCH HIGH AS WE CAN TO MAINTAIN THE BLOOD PRESSURE OF THE PATIENT.
THIS CAN BE DONE BY GIVING FLUIDS AND SIMULTANEOUSLY KEEPING CHECK ON THE LEFT HEART PRESSURE i.e. PCWP.
IF WE GIVE TOO MUCH OF FLUID THEN PCWP MAY INCREASE AND PATIENT MAY DEVELOP PILMONARY EDEMA AND BECOME HYPOXIC. SO PCWP HAS TO BE ACCURATELY MONITORED AND MAINTAINED OPTIMALLY WHEN YOU GIVE FLUIDS TO THESE PATIENTS.
I HOPE THAT EXPLAINS YOUR QUESTION SMITHA.
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| shirish_sss
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AND ONE MORE THING TO ADD TO THIS.
THE IDEAL RANGE OF PCWP IS APP. 20 mm Hg
1) IF IN A PATIENT OF ACUTE MI WHO HAS HYPOTENSION AND PCWP IS LOWER THAN THIS VALUE THEN SUSPECT HYPOVOLEMIA AND TREAT HIM BY GIVING IV FLUIDS AND SIMULTANEOUSLY MEASURING PCWP.
2) IF IN A PATIENT OF ACUTE MI AND HYPOTENSION IF THE PCWP IS MORE THAN THIS VALUE THEN THE PATIENT IS HAVING ACUTE PUMP FAILURE OR WHAT WE CALL ACUTE LVF. THIS KIND OF PATIENT IN FACT NEED TREATMENT WITH DIURETICS RATHER THAN FLUID REPLACEMENT BECAUSE HE IS AT A RISK FOR DEVELOPING PULMONARY EDEMA.. AND BEST FOR THESE PATIENTS WOULD BE WHAT WE CALL INTRA-AORTIC BALOON COUNTER PULSATION OR IABP. SINCE IT HELPS IMPROVE LEFT HEART FUNCTION.
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| smitha
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That's another very good piece of info shirish .......Thanx!!!!!!
But, i wud like u to look at the rt. atrial pressure too, which is HIGH here........... 
The Swan-Ganz tracing indicates that the patient has an elevated right-sided pressure and a low-filling pressure. Cardiac output is decreased as a result of insufficient left heart filling pressures. This is due to the RIGHT ventricular infarct, which causes backing up of venous blood and decreased forward flow, producing a decrease in left ventricular filling, as indicated by the low wedge pressure. The treatment for this patient is aggressive fluid administration.
The patient had a right ventricular infarct, presumably from involvement of the right coronary artery. Balloon angioplasty (choice A) may ultimately be needed to correct the underlying cause of the infarction. However, the acute event has passed, and the patient must first be stabilized. She will ultimately need a cardiac catheterization.
Digoxin (choice B) is not needed in this patient, since she is not in left sided heart failure. Positive inotropy is not needed as much as fluid resuscitation. Also, the patient is not in atrial fibrillation.
If the patient had sustained a left ventricular infarct, she may have needed afterload reduction in the form of intraaortic balloon counterpulsation (choice D). Since the patient sustained a right ventricular infarct, however, afterload reduction is not as important as is preload repletion.
The patient is hypotensive. If the hypotension does not resolve with fluid repletion, then vasopressors such as norepinephrine may be needed (choice E). However, fluid resuscitation must be continued.
AND here i wud like to review certan things...........which wud help u anwer the qs...........
LOW PCWP + LOW RAP: Blood loss, fluid loss, sepsis etc(anything which causes hypovolemia)
LOW PCWP+HIGH RAP: Pulmonary embolism, Rt. ventricular infarct...
HIGH PCWP+NORMAL RAP: LVF, MS.....
HIGH PCWP+HIGH RAP:constrictive pericarditis/tamponade......
Hope this piece of info added to urs will help..............
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THAT WAS EXCELLENT INFORMATION SMITHA
THANX VERY MUCH........................................................
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| shirish_sss
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EXCELLENT SMITHA.....
THAT HELPS WELL TO CLEAR ALL MY DOUBTS BOUT VARIOUS COMBINATIONS OF PCWP AND RAP
THANK YOU VERY MUCH................
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| damacharla
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guys,
in real world never depend upon swan numders.It only gives the clue but best thing is your clinical judgement
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| shirish_sss
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YA DAMACHARLA
I TOTALLY AGREE WITH YOU.......
BUT THE BOARDS SOMEHOW DOESN'T KNOW ABOUT THE REAL WORLD... :roll: :roll:
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| smitha
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ya damacharla..........i agree with shirish.....
Sometimes i feel different/odd to post certain qs & info which r LIMITED to the BOARDS WORLD & not REAL WORLD.........well, wat else can we do other than just getting on with wat we have to do for BOARDS here in this forum, rather than the real world.........
We need to cross this hurdle of BOARDS WORLD for us to get into & practice the REAL WORLD..........
And the real world discussions, i must say, r absolutely amazing at different sites, if u look for..................
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Yes u r totally right.....
But what clinical judgement can make u differnetiate between hypotension from left ventricular failure or hypovolemia or right ventricular failure or Pulmonary emblism or cardiac tamponade or valvular rupture....etc..
Plenty of causes of hypotension in AMI.
In some good clinical setting (tertiary health center where i hope all of us will be doing our residency in a good hopsital), Swan-Ganz saves lives and clincal judgement is used to assess swan and know when to ask for it.....
Plus how could you send a patient for baloon counterpulsation without documenting cardiac chamber pressures.... :!:
Now answer this one.
What are the different causes for Hypovolemia in AMI?
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| shirish_sss
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HI DEAR GUEST......
WELCOME TO THE FORUM...................
FIRST OF ALL A PATIENT OF ACUTE AMI IS ALWAYS MANAGED IN A TERTIARY CARE CENTRE AND NOT THE PRIMARY CARE CENTRE......
AND REGARDING YOUR QUESTION .....
THE ANSWER FOR THAT IS IN MY FIRST REPLY TO SMITHA'S QUESTION.....
THAT WAS ACTUALLY QUOTED FROM HARRISON'S VOLUME ONE-PAGE 1394
YOU CAN CHECK IT OUT.....
AND ONE MORE THING ...
I THINK WE HAD ENOUGH DISCUSSIONS ON THIS PARTICULAR SUBJECT SO FAR...
SO ME AND SMITHA WILL NOT BE POSTING ANY REPLIES TO ANY QUERIES ANY MORE....
YES GUYS THERE R LOTS OF DIFFERENT THINGS TO BE DISCUSSED APART FROM THIS ONE.........
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| smitha
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ok guys cool ........i guess sirish, here , guest is just trying to make a point saying that swan ganz catheter measurement IS ESSENTIAL for any further intervention in many different causes of hypotension due to AMI, and just clinical judgement is not sufficient, as damacharla mentioned above, that's all!!!!!!! and i guess i agree & we all shud i suppose!!!!!!! :wink:
And the reasons for hypotension in AMI, r already mentioned above dear guest........to bring them together again for u......
1. diaphoresis
2.vomiting
3.decreased venous tone
4.medications like diuretics, beta blockers, nitrates, morphine, calcium channel blockers and thrombolytics
5. lack of oral intake
6. rt. ventricular infarction.(look at my case, guest......this is the example)
i hope they r fine & if anything left or more in ur info store, plzzz , ur wlecome to post guest, and anyone of u.........ok??????
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THNX SMITHA........
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| shirish_sss
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THNHX SMITHA...... :lol: :lol:
AND THANX GUEST...... :lol: :lol:
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| smitha
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sources: NMSR, usmle.net,CMDT.
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