Initial assessment and triage US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Initial assessment and triage. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Initial assessment and triage US Medical PG Question 1: A 66-year-old man comes to the emergency department because of a 1-day history of chest pain, palpitations, and dyspnea on exertion. He had a similar episode 3 days ago and was diagnosed with an inferior wall myocardial infarction. He was admitted and a percutaneous transluminal coronary angioplasty was successfully done that day. A fractional flow reserve test during the procedure showed complete resolution of the stenosis. Laboratory tests including serum glucose, lipids, and blood count were within normal limits. He was discharged the day after the procedure on a drug regimen of aspirin, simvastatin, and isosorbide dinitrate. At the time of discharge, he had no chest pain or dyspnea. Presently, his vitals are normal and ECG at rest shows new T-wave inversion. Which of the following is the most reliable test for rapidly establishing the diagnosis in this patient?
- A. Creatine kinase MB
- B. Lactate dehydrogenase
- C. Copeptin
- D. Aspartate aminotransferase
- E. Cardiac troponin T (Correct Answer)
Initial assessment and triage Explanation: ***Cardiac troponin T***
- **Cardiac troponin T** is a highly sensitive and specific biomarker for **myocardial injury**, making it the most reliable test for rapidly diagnosing acute coronary syndrome or re-infarction.
- Its elevation indicates ongoing **myocardial necrosis**, even after a recent MI, and is crucial for guiding immediate management.
*Creatine kinase MB*
- While CK-MB is used for diagnosing myocardial infarction, its levels can also be elevated in cases of **skeletal muscle injury** or **after cardiac procedures**, reducing its specificity in this context.
- CK-MB also has a **shorter window of elevation** compared to troponins, potentially missing later presentations of myocardial injury.
*Lactate dehydrogenase*
- **LDH** is a relatively **nonspecific marker** that can elevate due to various conditions affecting different organs (e.g., liver disease, hemolysis, renal injury).
- Its elevation onset is **slower** and its diagnostic window is longer, making it less suitable for rapid diagnosis of acute myocardial injury.
*Copeptin*
- **Copeptin** is a marker of **endogenous stress** and is often used in conjunction with troponins to rule out NSTEMI, especially at early presentation.
- However, it is not a direct marker of myocardial necrosis itself and is **not as specific** as troponin for diagnosing a re-infarction.
*Aspartate aminotransferase*
- **AST** is a **nonspecific enzyme** found in various tissues, including the liver, skeletal muscle, and heart.
- Elevated AST levels are frequently seen in **liver damage** and are not a primary biomarker for diagnosing acute myocardial infarction or re-infarction.
Initial assessment and triage US Medical PG Question 2: A cardiologist is studying how a new virus that infects the heart affects the electrical conduction system of the cardiac myocytes. He decides to obtain electrocardiograms on patients with this disease in order to see how the wave patterns and durations change over time. While studying these records, he asks a medical student who is working with him to interpret the traces. Specifically, he asks her to identify the part that represents initial ventricular depolarization. Which of the following characteristics is most consistent with this feature of the electrocardiogram?
- A. Elevated in patients with full thickness ischemic injury of the heart
- B. Becomes peaked in states of hyperkalemia
- C. Becomes prominent in states of hypokalemia
- D. Normal duration defined as less than 120 milliseconds (Correct Answer)
- E. Normal duration defined as less than 200 milliseconds
Initial assessment and triage Explanation: ***Normal duration defined as less than 120 milliseconds***
- The question asks for the representation of **initial ventricular depolarization**, which corresponds to the **QRS complex** on an ECG.
- The normal duration of the **QRS complex** is typically less than **0.12 seconds (120 milliseconds)**, reflecting efficient ventricular depolarization.
*Elevated in patients with full thickness ischemic injury of the heart*
- This description refers to the **ST segment elevation** seen in **ST-segment elevation myocardial infarction (STEMI)**, which represents myocardial injury, not initial ventricular depolarization.
- While related to cardiac electrical activity, **ST segment elevation** is a consequence of injury and refers to repolarization abnormalities, not the QRS complex itself.
*Becomes peaked in states of hyperkalemia*
- **Peaked T waves** are characteristic of **hyperkalemia**, indicating altered ventricular repolarization, not ventricular depolarization.
- The T wave represents ventricular repolarization, and its morphology changes significantly with potassium imbalances.
*Becomes prominent in states of hypokalemia*
- A **prominent U wave** is sometimes observed in **hypokalemia**, which follows the T wave and is thought to represent repolarization of Purkinje fibers.
- The U wave is distinct from the QRS complex and does not represent initial ventricular depolarization.
*Normal duration defined as less than 200 milliseconds*
- A duration of less than 200 milliseconds (0.20 seconds) typically refers to the normal duration of the **PR interval**, which represents atrial depolarization and conduction through the AV node.
- The **QRS complex** (initial ventricular depolarization) has a shorter normal duration, typically less than 120 milliseconds.
Initial assessment and triage US Medical PG Question 3: A 67-year-old man presents to the emergency department for squeezing and substernal chest pain. He states that he was at home eating dinner when his symptoms began. The patient has a past medical history of diabetes, hypertension, and dyslipidemia. He is currently taking atorvastatin, lisinopril, insulin, metformin, metoprolol, and aspirin. Six days ago he underwent percutaneous coronary intervention. His temperature is 99.5°F (37.5°C), blood pressure is 197/118 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals an uncomfortable elderly man who is sweating. An ECG is ordered. Which of the following is the best next step in management for this patient?
- A. Stress testing
- B. Angiography (Correct Answer)
- C. Cardiac troponins
- D. Creatine kinase-MB
- E. Myoglobin
Initial assessment and triage Explanation: ***Correct: Angiography***
- This patient presenting with **acute chest pain 6 days post-PCI** is at high risk for **stent thrombosis or acute in-stent restenosis**, which represents a life-threatening emergency.
- Given the **clinical instability** (severe hypertension 197/118, tachycardia 120/min, diaphoresis) and classic ACS symptoms in the immediate post-PCI period, **urgent coronary angiography** is the best next step in management.
- While ECG and troponins are important diagnostic tools, this patient requires **immediate intervention** to evaluate the recent PCI site and potentially perform emergent revascularization.
- In the setting of suspected **acute stent thrombosis**, time to reperfusion is critical, and angiography allows both diagnosis and treatment.
*Incorrect: Cardiac troponins*
- While troponins are essential biomarkers for myocardial injury and should be obtained, they are a **diagnostic test** rather than definitive management.
- Waiting for troponin results would delay definitive management in a patient with clear clinical evidence of ACS.
- In this high-risk post-PCI patient with active symptoms, management should not wait for biomarker confirmation.
*Incorrect: Stress testing*
- Stress testing is **absolutely contraindicated** in patients with active chest pain and suspected acute MI.
- It could precipitate further myocardial ischemia, arrhythmias, or cardiac arrest.
- Stress testing is reserved for risk stratification in stable patients or after ACS has been ruled out.
*Incorrect: Creatine kinase-MB*
- CK-MB is less sensitive and specific than troponins for myocardial injury, as it can be elevated in skeletal muscle conditions.
- It has a shorter elevation window and has largely been replaced by troponins in modern practice.
- Like troponins, it would not change the immediate management need in this clinically unstable patient.
*Incorrect: Myoglobin*
- Myoglobin lacks cardiac specificity (present in both cardiac and skeletal muscle) and has poor diagnostic accuracy for MI.
- Its rapid rise and fall make it unreliable, and it generates many false positives.
- It has no role in guiding management decisions in suspected ACS.
Initial assessment and triage US Medical PG Question 4: Serum studies show a troponin T concentration of 6.73 ng/mL (N < 0.01), and fingerstick blood glucose concentration of 145 mg/dL. The cardiac catheterization team is activated. Treatment with unfractionated heparin, aspirin, ticagrelor, and sublingual nitroglycerin is begun, and the patient's pain subsides. His temperature is 37.3°C (99.1°F), pulse is 65/min, respirations are 23/min, and blood pressure is 91/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Which of the following is the most appropriate additional pharmacotherapy?
- A. Intravenous morphine
- B. Intravenous furosemide
- C. Intravenous insulin
- D. Oral atorvastatin (Correct Answer)
- E. Intravenous nitroglycerin
Initial assessment and triage Explanation: ***Oral atorvastatin***
- All patients with **acute coronary syndrome (ACS)** should receive high-intensity statin therapy, such as **atorvastatin 80 mg daily**, as early as possible.
- Statins stabilize plaques, reduce inflammation, and improve endothelial function, which are crucial in the acute setting of a myocardial infarction.
*Intravenous morphine*
- Morphine can be used for persistent chest pain refractory to nitroglycerin, but its routine use is now questioned due to potential adverse effects like hypotension and delayed antiplatelet absorption.
- The patient's pain has already subsided with initial treatment, and his blood pressure is already low (91/60 mm Hg), making morphine less appropriate.
*Intravenous furosemide*
- Furosemide is a loop diuretic primarily used for treating **fluid overload** and **pulmonary edema**, which are not indicated by the patient's current presentation (oxygen saturation 96%, no mention of crackles or dyspnea).
- Its use in a patient with **borderline hypotension** could worsen hemodynamic stability.
*Intravenous insulin*
- While the patient has elevated fingerstick glucose (145 mg/dL), this level does not immediately require intravenous insulin unless there is evidence of **diabetic ketoacidosis** or **hyperosmolar hyperglycemic state**, or persistent severe hyperglycemia.
- More moderate hyperglycemia can often be managed with subcutaneous insulin or diet in the acute phase, and focuses remain on cardiac stabilization.
*Intravenous nitroglycerin*
- Intravenous nitroglycerin is indicated for ongoing ischemic chest pain or uncontrolled hypertension in ACS, but the patient's pain has subsided and he is **hypotensive** (91/60 mm Hg).
- Administering more nitroglycerin would likely worsen his hypotension and could compromise coronary perfusion.
Initial assessment and triage US Medical PG Question 5: A 60-year-old man presents to the emergency department with progressive dyspnea for the last 3 weeks. He complains of shortness of breath while lying flat and reports nighttime awakenings due to shortness of breath for the same duration. The patient has been a smoker for the last 30 years. Past medical history is significant for myocardial infarction 7 months ago. Current medications include metoprolol, aspirin, and rosuvastatin, but the patient is noncompliant with his medications. His temperature is 37.2°C (98.9°F), the blood pressure is 150/115 mm Hg, the pulse is 110/min, and the respiratory rate is 24/min. Oxygen saturation on room air is 88%. Chest auscultation reveals bilateral crackles and an S3 gallop. On physical examination, the cardiac apex is palpated in left 6th intercostal space. Bilateral pitting edema is present, and the patient is in moderate distress. Which of the following is the best next step in the management of the patient?
- A. Intravenous beta blockers
- B. Intravenous diuretics (Correct Answer)
- C. Echocardiography
- D. Cardiac stress testing
- E. Intravenous inotropes
Initial assessment and triage Explanation: ***Intravenous diuretics***
- The patient presents with classic signs and symptoms of **acute decompensated heart failure**, such as progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral crackles, S3 gallop, pitting edema, and elevated blood pressure with elevated heart rate due to fluid overload.
- **Intravenous loop diuretics** (e.g., furosemide) are the most appropriate initial therapy to reduce preload, alleviate pulmonary and systemic congestion, and improve oxygenation.
*Intravenous beta blockers*
- While beta-blockers are a cornerstone of chronic heart failure management, **starting or acutely increasing beta-blocker dosage in acute decompensated heart failure** can worsen cardiac output and lead to symptomatic hypotension or cardiogenic shock.
- Beta-blockers should generally be withheld or reduced during acute exacerbations and reinstituted once the patient is stable.
*Echocardiography*
- While an **echocardiogram** is essential for diagnosing the underlying cause and assessing cardiac function in heart failure, it is not the *best next step* in a patient presenting with acute, severe symptoms requiring immediate stabilization.
- The patient's acute respiratory distress and hypoxemia necessitate immediate medical intervention to reduce fluid overload before detailed diagnostic imaging.
*Cardiac stress testing*
- **Cardiac stress testing** is used to evaluate for inducible ischemia in stable patients and is not appropriate in the setting of acute decompensated heart failure.
- Performing a stress test on a patient with signs of fluid overload and respiratory distress would be dangerous and could exacerbate their condition.
*Intravenous inotropes*
- **Intravenous inotropes** (e.g., dobutamine, milrinone) are typically reserved for patients with evidence of **cardiogenic shock** or severe heart failure with persistent hypoperfusion despite optimal fluid management and diuretic therapy.
- This patient, while acutely ill, primarily exhibits signs of fluid overload without clear evidence of severe hypoperfusion compromising end-organ function.
Initial assessment and triage US Medical PG Question 6: A 70-year-old man with diabetes, hypertension, and chronic kidney disease (eGFR 35 mL/min/1.73m²) presents with NSTEMI. Troponin is elevated at 8.5 ng/mL. ECG shows 2mm ST depression in V2-V5. GRACE score is 165 (high risk). He is hemodynamically stable. Cardiologist recommends early invasive strategy within 24 hours. Nephrologist is concerned about contrast-induced nephropathy potentially requiring dialysis. Patient is on metformin. Evaluate the management strategy integrating multiple specialist perspectives and evidence.
- A. Proceed with angiography within 24 hours using iso-osmolar contrast and intravenous hydration, hold metformin (Correct Answer)
- B. Perform coronary CT angiography as alternative to invasive angiography
- C. Delay catheterization for 72 hours to optimize renal function with hydration
- D. Prophylactic hemodialysis before and after catheterization to remove contrast
- E. Medical management only with dual antiplatelet therapy, avoid catheterization
Initial assessment and triage Explanation: ***Proceed with angiography within 24 hours using iso-osmolar contrast and intravenous hydration, hold metformin***
- High-risk NSTEMI patients with a **GRACE score >140** benefit from an **early invasive strategy** within 24 hours to reduce ischemic events and mortality.
- Renal protection is maximized through **pre-procedural hydration** and **iso-osmolar contrast**, while **metformin** must be held to avoid the risk of lactic acidosis if acute kidney injury occurs.
*Perform coronary CT angiography as alternative to invasive angiography*
- **Coronary CTA** is primarily used for ruling out coronary artery disease in low-to-intermediate risk stable patients, not for high-risk **NSTEMI**.
- This modality still requires **iodinated contrast** and does not provide the therapeutic benefit of percutaneous coronary intervention (**PCI**).
*Delay catheterization for 72 hours to optimize renal function with hydration*
- Delaying the procedure in a high-risk patient increases the risk of **re-infarction** and **cardiovascular death**, outweighing the minor benefits of prolonged hydration.
- Evidence suggests that optimization of renal status should happen concurrently with the preparation for **early intervention** in high-risk ACS.
*Prophylactic hemodialysis before and after catheterization to remove contrast*
- **Prophylactic hemodialysis** has not been proven to prevent contrast-induced nephropathy and may actually increase the risk of adverse events.
- High-volume **intravenous hydration** with isotonic saline remains the gold standard for preventing renal injury in patients with **CKD**.
*Medical management only with dual antiplatelet therapy, avoid catheterization*
- While **dual antiplatelet therapy** is essential, medical management alone is inferior to an invasive strategy in patients with **high GRACE scores**.
- Avoiding catheterization based solely on **renal impairment** results in "renalism," where patients are undertreated for their life-threatening cardiac condition.
Initial assessment and triage US Medical PG Question 7: A 58-year-old woman with anterior STEMI underwent primary PCI with drug-eluting stent placement. Post-procedure echocardiogram shows left ventricular ejection fraction of 30% with apical akinesis. She is started on aspirin, ticagrelor, high-intensity statin, and ACE inhibitor. On hospital day 3, she develops atrial fibrillation with rapid ventricular response. CHA2DS2-VASc score is 4. Creatinine is normal. Evaluate the optimal antithrombotic strategy balancing ischemic and bleeding risk.
- A. Triple therapy with aspirin, ticagrelor, and apixaban indefinitely
- B. Triple therapy for 6 months, then aspirin and apixaban indefinitely
- C. Aspirin and ticagrelor only, hold anticoagulation due to bleeding risk
- D. Warfarin with INR 2-3 plus aspirin, discontinue ticagrelor
- E. Triple therapy for 1 month, then apixaban and clopidogrel for 11 months, then apixaban alone (Correct Answer)
Initial assessment and triage Explanation: ***Triple therapy for 1 month, then apixaban and clopidogrel for 11 months, then apixaban alone***
- In patients with **Atrial Fibrillation** (CHA2DS2-VASc ≥2) undergoing **PCI**, current guidelines recommend minimizing the duration of **triple therapy** (aspirin, P2Y12 inhibitor, and anticoagulant) to 1 week to 1 month to reduce **bleeding risk**.
- Transitioning to **dual therapy** with a **NOAC** (like apixaban) and a P2Y12 inhibitor (preferably **clopidogrel**) for up to 12 months, followed by NOAC monotherapy, provides an optimal balance between preventing **stent thrombosis** and systemic **thromboembolism**.
*Triple therapy with aspirin, ticagrelor, and apixaban indefinitely*
- Indefinite **triple therapy** carries a prohibitively high risk of life-threatening **major bleeding** without added benefit for stroke prevention.
- **Ticagrelor** is generally avoided in triple therapy regimens due to a significantly higher bleeding profile compared to **clopidogrel**.
*Triple therapy for 6 months, then aspirin and apixaban indefinitely*
- **Triple therapy** for 6 months is rarely indicated and significantly increases the risk of **gastrointestinal and intracranial hemorrhage** compared to the 1-month strategy.
- Aspirin is usually discontinued after the first year in favor of **anticoagulant monotherapy**, as the latter is sufficient for both AF and stable CAD protection.
*Aspirin and ticagrelor only, hold anticoagulation due to bleeding risk*
- This approach leaves the patient with a high **CHA2DS2-VASc score of 4** unprotected against **cardioembolic stroke**, which carries high morbidity and mortality.
- Dual antiplatelet therapy (DAPT) alone is significantly less effective than **oral anticoagulants** for stroke prevention in the setting of atrial fibrillation.
*Warfarin with INR 2-3 plus aspirin, discontinue ticagrelor*
- **NOACs** (like apixaban) are now preferred over **Warfarin** for non-valvular AF due to a superior safety profile, including a lower risk of **intracranial hemorrhage**.
- Discontinuing the P2Y12 inhibitor (ticagrelor) immediately post-PCI in favor of aspirin and warfarin significantly increases the risk of **stent thrombosis**.
Initial assessment and triage US Medical PG Question 8: A 60-year-old man with inferoposterior STEMI presents to a rural hospital. The nearest PCI-capable facility is 3 hours away. He arrives 90 minutes after symptom onset. Blood pressure is 130/85 mmHg, heart rate 88/min, oxygen saturation 96% on room air. He has no contraindications to fibrinolysis. The transfer team can arrive in 30 minutes. Evaluate the evidence-based approach considering time metrics and available resources.
- A. Immediate fibrinolytic therapy followed by transfer (Correct Answer)
- B. Helicopter transfer to reduce transfer time, then primary PCI
- C. Administer half-dose fibrinolytic and transfer for immediate PCI
- D. Fibrinolytic therapy at rural hospital, transfer only if fails
- E. Wait for transfer team and proceed directly to PCI facility
Initial assessment and triage Explanation: ***Immediate fibrinolytic therapy followed by transfer***
- In a STEMI patient where the expected **door-to-balloon time** exceeds **120 minutes**, and the patient is seen within **12 hours** of symptom onset, **fibrinolytic therapy** is the preferred reperfusion strategy.
- Following fibrinolysis, a **pharmacoinvasive strategy** is recommended, involving a routine transfer to a PCI-capable center for angiography within **3 to 24 hours**.
*Helicopter transfer to reduce transfer time, then primary PCI*
- Even with expedited transport, the distance and total time likely still exceed the recommended **120-minute window** for primary PCI superiority over fibrinolysis.
- Choosing transfer over immediate thrombolysis in a rural setting when delays are significant increases the risk of **myocardial necrosis**.
*Administer half-dose fibrinolytic and transfer for immediate PCI*
- **Half-dose fibrinolytics** are generally only considered in specific subsets like elderly patients (over 75) to reduce **intracranial hemorrhage** risk, which does not apply here.
- Combining half-dose thrombolysis with immediate PCI (facilitated PCI) has not shown superior outcomes and may increase **bleeding complications**.
*Fibrinolytic therapy at rural hospital, transfer only if fails*
- Modern guidelines recommend a **pharmacoinvasive approach**, meaning all patients should be transferred for **coronary angiography** regardless of clinical success of fibrinolysis.
- Waiting only for "failure" (rescue PCI) ignores the benefit of definitive **revascularization** and stabilization provided by routine post-thrombolysis PCI.
*Wait for transfer team and proceed directly to PCI facility*
- Delaying reperfusion for a 3-hour transport window violates the "**time is muscle**" principle, as the patient is currently in the highly time-sensitive **early window** (under 3 hours).
- Failure to administer fibrinolytics when the **PCI-related delay** is over 90-120 minutes is a deviation from standard **STEMI management protocols**.
Initial assessment and triage US Medical PG Question 9: A 65-year-old man with extensive anterior STEMI underwent PCI 6 hours after symptom onset due to delayed presentation. Peak troponin was significantly elevated. Three days later, he develops progressive dyspnea. Examination reveals a new holosystolic murmur at the apex radiating to the axilla. Echocardiogram shows severe mitral regurgitation with flail posterior leaflet and hyperdynamic left ventricle. Pulmonary capillary wedge pressure tracing shows prominent v waves. He is euvolemic on examination. Analyze this complication to determine timing of intervention.
- A. Immediate surgical mitral valve repair or replacement
- B. Aggressive diuresis and ACE inhibitor, reassess in 2 weeks
- C. Intra-aortic balloon pump with surgery within 24-48 hours (Correct Answer)
- D. Percutaneous mitral valve repair with MitraClip
- E. Medical management with afterload reduction for 6 weeks, then surgery
Initial assessment and triage Explanation: ***Intra-aortic balloon pump with surgery within 24-48 hours***
- **Acute papillary muscle rupture** leads to severe mitral regurgitation and hemodynamic instability; an **IABP** provides essential **afterload reduction** and increases forward flow while reducing the regurgitant fraction.
- Providing a brief period of stabilization for 24-48 hours allows for therapeutic optimization before **urgent surgical intervention**, balancing the high risk of immediate surgery with the extreme mortality of medical delay.
*Immediate surgical mitral valve repair or replacement*
- Performing surgery immediately upon diagnosis carries an exceptionally high mortality rate due to the **friable, necrotic myocardial tissue** that is difficult to suture.
- While definitive, Proceeding without initial **hemodynamic stabilization** (like IABP) increases the risk of intraoperative cardiovascular collapse.
*Aggressive diuresis and ACE inhibitor, reassess in 2 weeks*
- This patient has a mechanical complication (flail leaflet); medical management alone for **acute MR** has a mortality rate exceeding 90%.
- **ACE inhibitors** may be poorly tolerated in the acute setting of a large MI if the patient becomes hypotensive, and waiting 2 weeks is far too long for a **mechanical emergency**.
*Percutaneous mitral valve repair with MitraClip*
- **MitraClip** is primarily indicated for chronic secondary MR or in patients with prohibitive surgical risk, rather than as first-line treatment for **acute post-MI papillary muscle rupture**.
- The necrotic and distorted nature of the **subvalvular apparatus** in an acute rupture makes it a poor substrate for percutaneous repair techniques.
*Medical management with afterload reduction for 6 weeks, then surgery*
- Delaying surgery for 6 weeks for "tissue healing" is inappropriate for **papillary muscle rupture** as the patient will likely suffer from progressive **pulmonary edema** or cardiogenic shock.
- While chronic MR can be managed medically, **acute structural failure** requires urgent mechanical correction once stable, not prolonged medical therapy.
Initial assessment and triage US Medical PG Question 10: A 72-year-old man with inferior STEMI underwent successful PCI 5 days ago. He develops sudden onset dyspnea and hypotension. Blood pressure is 75/50 mmHg with pulsus paradoxus of 20 mmHg. Jugular venous pressure is elevated with prominent x descent. Emergent echocardiography shows large pericardial effusion with right atrial and ventricular diastolic collapse. The patient is on aspirin, clopidogrel, and therapeutic enoxaparin. Analyze the complication and optimal intervention strategy.
- A. Immediate surgical exploration and repair (Correct Answer)
- B. Administer protamine and fresh frozen plasma, then observe
- C. Discontinue anticoagulation and observe with serial echocardiograms
- D. Increase intravenous fluid administration
- E. Urgent pericardiocentesis followed by surgical evaluation
Initial assessment and triage Explanation: ***Immediate surgical exploration and repair***
- The patient presents with **free wall rupture** leading to **cardiac tamponade**, a lethal post-MI complication typically occurring 3 to 7 days after the event.
- Definitive treatment for mechanical rupture requires **emergent surgery** to repair the defect, as conservative management carries a near 100% mortality rate.
*Administer protamine and fresh frozen plasma, then observe*
- While reversing **anticoagulation** is important, observation is inappropriate for a patient with **mechanical rupture** and obstructive shock.
- Delaying surgery for medical reversal will likely result in **cardiac arrest** due to rapid hemodynamic collapse.
*Discontinue anticoagulation and observe with serial echocardiograms*
- Discontinuing medication addresses the risk of hemorrhage but fails to manage the primary **ventricular wall defect**.
- **Serial echocardiograms** are indicated for stable pericarditis, not a patient with **hypotension** and right heart collapse.
*Increase intravenous fluid administration*
- IV fluids can be a temporary bridge to maintain **preload** during tamponade, but they are never a curative or primary strategy.
- Over-reliance on fluid resuscitation delays the necessary **surgical decompression** and defect repair required for survival.
*Urgent pericardiocentesis followed by surgical evaluation*
- While it can relieve pressure, **pericardiocentesis** is often contraindicated in free wall rupture as it can dislodge a clot and **exacerbate bleeding**.
- Immediate transition to the **operating room** is the priority over bedside drainage in the setting of post-MI mechanical complications.
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