A 65-year-old woman with a history of diabetes, hypertension, depression, and anxiety is evaluated in the emergency department for severe substernal chest pain with nausea and vomiting. She recently lost her husband to cancer and just found out that her son was killed in a car accident this morning. On arrival, vital signs are: temperature 37°C (98.6°F), heart rate 120 beats/min, blood pressure 90/60 mm Hg, respiratory rate 24 breaths/min, oxygen saturation 92% on 6 liters/min nasal cannula. Physical examination is notable for crackles in the lung bases and cool extremities. ECG shows ST elevation in leads V1-V3 with T wave inversions in leads I and aVL. Chest radiograph shows mild pulmonary edema.She is started on aspirin, clopidogrel, and a heparin infusion, while being given a 1-liter IV normal saline bolus as she is taken up to the catheterization laboratory for a percutaneous coronary intervention. She is noted to have small amounts of plaque with less than 30% stenosis in her left anterior descending and right coronary arteries. Left ventriculography reveals apical ballooning with vigorous contraction of the basal segment. Echocardiography shows evidence of left ventricular outflow tract obstruction (see below). During the procedure, her oxygen saturations drop to 70% despite a nonrebreather mask, and her blood pressure is now 70/40 mm Hg, with a heart rate of 130 beats/min, and she is confused.
Which of the following is the most appropriate hemdynamic support strategy for this patient?
A. Intubate and start dobutamine and norepinephrine.
B. Intubate and start IV esmolol and phenylephrine.
C. Intubate and give a 1-liter IV normal saline bolus.
D. Begin bilevel positive airway pressure, and start dobutamine and norepinephrine.
中文翻譯：
急診室對一名患有糖尿病、高血壓、抑鬱症和焦慮病史的65歲女性進行了評估，評估其嚴重的胸骨後胸痛伴噁心和嘔吐。她的丈夫最近因癌症去世，而今天早上她的兒子也在一場車禍中喪生。到達急診時她的生命體徵為：溫度37°C（98.6°F），心率120次/分鐘，血壓90/60 mmHg，呼吸頻率24次/分鐘，氧飽和度92％（6升/分鐘鼻導管吸氧）。體格檢查發現肺基部可及溼羅音和四肢冰涼。心電圖顯示V1-V3導聯的ST升高，而I和aVL導聯的T波反轉。胸部X光片顯示輕度肺水腫。
她開始接受阿司匹林，氯吡格雷和肝素輸注，然後在介入導管室進行經皮冠狀動脈介入治療時接受1升生理鹽水的滴注。術中發現她的左前降支和右冠狀動脈斑塊少，狹窄少於30％。左心室造影顯示根尖膨大，基底節段劇烈收縮。超聲心動圖顯示左心室流出道梗阻的證據（見下圖）。在手術過程中，儘管佩戴呼吸面罩但她的血氧飽和度下降到70％，並且她的血壓現在為70/40 mmHg，心率為130次/分鐘，她感到困惑。