ICU BasicsA patient with an inferior STEMI has BP 78/50 mm Hg, clear lung fields, and jugular venous distension. Values: CVP 18, PAOP 8, CI 1.8. Which intervention is MOST appropriate while awaiting revascularization?
- Sublingual nitroglycerin for ongoing chest pain
- IV morphine 4 mg to relieve pain and lower O₂ demand
- IV furosemide to lower the elevated CVP
- A cautious fluid bolus to support RV preload
Why each answer is right or wrong
Answer: D
- A. Nitrates reduce preload and can cause profound hypotension in RV infarction.
- B. Morphine causes venodilation and can worsen hypotension from reduced preload.
- C. Diuresis lowers RV preload and worsens output in RV infarction.
- D. Correct. RV infarction is preload-dependent, so a judicious fluid bolus can improve LV filling and output.
A high CVP with a normal or low PAOP, clear lungs, and hypotension during an inferior MI suggests right ventricular infarction (confirmed by ST elevation in V4R). The failing RV cannot push enough blood through the lungs to fill the LV. Management is judicious volume (watching for RV overdistension), avoiding preload reducers (nitrates, diuretics, morphine), maintaining AV synchrony (pacing for heart block), inotropes if needed, and urgent reperfusion.
Sources: AACN Essentials of Critical Care, 5th ed.; AACN Core Curriculum, 8th ed.; Jacobson, CV Nursing Practice, 3rd ed.
