A 76-Year-Old Man Is Admitted to the Hospital with Nausea

question 439

Multiple Choice

A 76-year-old man is admitted to the hospital with nausea, vomiting, and generalized abdominal distension.  He has a long-standing history of type 2 diabetes mellitus.  His medical follow-up has been poor.  Physical examination and diagnostic workup are consistent with a complicated small-bowel obstruction.  He undergoes exploratory laparotomy with no operative complications and is extubated postoperatively in the surgical intensive care unit.  A few hours after extubation, the patient experiences sudden onset of chest discomfort, nausea, and marked diaphoresis.  Temperature is 36.1 C (97 F) , blood pressure is 84/50 mm Hg, pulse is 32/min, and respirations are 26/min.  Examination shows minimal crackles at both bases.  There are no murmurs on cardiac examination.  Fingerstick glucose level is 150 mg/dL.  ECG shows sinus bradycardia with 3-mm ST-segment elevations in leads II, III, and aVF.  Immediate chest x-ray shows increased interstitial markings bilaterally.  Intravenous normal saline infusion is started and intravenous atropine is administered without significant improvement.  Which of the following is the most appropriate next step in management of this patient?

• A)Intravenous heparin infusion
• B)Low-dose dobutamine infusion
• C)Norepinephrine infusion
• D)Temporary cardiac pacing
• E)Thrombolytic therapy

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