A 65-year-old man with a history of hypertension is brought in by paramedics with 3 hours of dyspnea without chest pain. Paramedics state he became more fatigued and obtunded on the way into the ED. Vital signs are BP 172/108, HR 114, RR 30, T 98.6, O2 saturation 88% on continuous positive airway pressure (CPAP). The patient is unresponsive to voice, with clammy skin. Physical exam findings include JVD, diffuse rales, an S3 gallop, and mild pitting edema. What is the next most appropriate treatment for this patient?
Begin bioimpedance monitoring
+Endotracheal intubation
+Furosemide IV
+Increase CPAP pressure from 5 to 10 cm of water and readjust mask
+Start nitroglycerin IV drip
This patient requires immediate endotracheal intubation because he now has impaired consciousness and severe respiratory distress and has failed a trial of CPAP, a form of noninvasive ventilation. Readjusting his mask or increasing the pressure would be ineffective since he is now hypoxic and has a depressed sensorium. Although treatment with nitroglycerin followed by furosemide is indicated in this patient with probable pulmonary edema, control of airway takes precedence. Bioimpedance monitoring, which can noninvasively provide accurate information about cardiac output and thoracic water content, is a useful bedside adjunct for diagnosing and managing suspected heart failure in the ED and could be implemented after the airway is secured.