A 70 year old male with a past medical history coronary artery disease, heart failure with reduced ejection fraction, and severe aortic stenosis presents via EMS for shortness of breath. History is limited due to acute respiratory distress while patient is on CPAP. Vital signs are: BP 88/60, HR 120, T 36.7, RR 30, SpO2 90% on PEEP 8 and FiO2 100%. On exam, he is in severe respiratory distress with accessory muscle usage and speaks in 2 word phrases. There is a prominent systolic ejection murmur over the right second intercostal space. Rales are heard at the lung bases bilaterally, and there is 4+ pitting edema of the lower extremities. EKG shows sinus tachycardia. Which of the following is the preferred resuscitation strategy to optimize hemodynamics prior to intubation? 

A: bolus 1 liter isotonic fluids

B: epinephrine infusion 

C: norepinephrine infusion

D: phenylephrine infusion

E: push dose epinephrine prior to induction

Answer: phenylephrine infusion

This patient is presenting in acute hypoxic respiratory failure likely secondary to pulmonary edema related to acute on chronic heart failure. Patients with severe aortic stenosis are preload dependent to maintain coronary and systemic perfusion. Thus, typical management with positive airway pressure and nitrates should be used cautiously. In hypotensive patients with aortic stenosis, phenylephrine is the vasopressor of choice due to its pure alpha-1 agonist effects to increase diastolic blood pressure and coronary perfusion. Reflex bradycardia is also beneficial to allow for more diastolic filling time. Inotropes such as epinephrine are not recommended due to tachycardia and increased myocardial oxygen demand. Norepinephrine is a reasonable alternative but not the preferred agent. Fluid administration is likely to worsen this patient’s hemodynamics and respiratory status by volume overload.

References:

Goertz AW, Lindner KH, Schutz W, Schirmer U, Beyer M, Georgieff M. Influence of phenylephrine bolus administration on left ventricular filling dynamics in patients with coronary artery disease and patients with valvular aortic stenosis. Anesthesiology. 1994;81(1):49-58.

A 64 year old male with a past medical history of diabetes mellitus, coronary artery disease, and congestive heart failure is being evaluated for chest pain. His initial vital signs are within normal limits. His EKG is unchanged from previous showing a narrow-complex sinus rhythm. While he is in the emergency department, he reports feeling palpitations. The cardiac monitor records a monomorphic, wide-complex tachycardia at a rate of 140 beats/minute while his blood pressure is 132/80. What is the first-line medication for treatment of this patient’s condition?

A: adenosine

B: amiodarone

C: epinephrine

D: magnesium sulfate

E: procainamide

Answer: procainamide

This patient with a history of extensive cardiac disease is likely experiencing stable ventricular tachycardia (VT). The PROCAMIO study in 2017 demonstrated that procainamide is likely superior to amiodarone for termination of wide-complex tachycardia and associated with fewer major adverse cardiac events. Adenosine is commonly used in the management of supraventricular tachycardias but is unlikely to terminate a tachycardia of ventricular origin. Epinephrine is used for pulseless VT as part of the ACLS algorithm. Magnesium sulfate is used for polymorphic VT also known as Torsades De Pointes but is not first-line for monomorphic VT.

References:

Ortiz, M., Martín, A., Arribas, F., Coll-Vinent, B., Del Arco, C., Peinado, R., Almendral, J., & PROCAMIO Study Investigators (2017). Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. European heart journal, 38(17), 1329–1335. https://doi.org/10.1093/eurheartj/ehw230