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Dantrolene
6%
2/34
Lorazepam
0%
0/34
Phenoxybenzamine
82%
28/34
Phentolamine
3%
1/34
Propylthiouracil
9%
3/34
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This patient has a history of headaches and then presents during surgery with severe hypertension uncontrolled by labetalol, which suggests a diagnosis of pheochromocytoma. Patients with pheochromocytoma should be medically managed with phenoxybenzamine, a non-selective alpha-adrenergic blocker, prior to surgery. Patients with pheochromocytoma classically present with episodic headache, sweating, tachycardia, and paroxysmal hypertension. Patients with undiagnosed pheochromocytomas who undergo surgery without appropriate preoperative medical management have high surgical mortality due to hypertensive crises. These patients should be managed medically with alpha-adrenergic blockade. The irreversible alpha-blocker (phenoxybenzamine) must be administered prior to any beta-blocker to avoid unopposed alpha-adrenergic receptor stimulation, which can exacerbate hypertension. Surgical excision of the underlying lesion is definitive treatment. Farrugia and Charalampopoulos review the evidence regarding the diagnosis and treatment of patients with pheochromocytoma. They discuss how these patients should be managed with preoperative alpha-adrenergic followed by beta-adrenergic blockade. They recommend surgical excision of the lesion for definitive treatment. Incorrect Answers: Answer 1: Dantrolene is used in the treatment of malignant hyperthermia and neuroleptic malignant syndrome (NMS). Both malignant hyperthermia and NMS would additionally present with fever, and neither would explain this patient’s headaches. Rapid identification, administration of dantrolene, and systemic cooling prevent irreversible damage. Answer 2: Lorazepam may be used in the treatment of serotonin syndrome. Although this patient’s sertraline is a selective serotonin reuptake inhibitor, patients with serotonin syndrome usually have a history of multiple pro-serotonergic medications. Patients would additionally present with hyperthermia, clonus, and muscle rigidity. Answer 4: Phentolamine is a short-term alpha-1 blocking agent that would be appropriate for treating a hypertensive crisis. However, the best drug for preventing this complication would be to administer phenoxybenzamine prior to surgery (given it has a long half-life). Phentolamine could be used to treat the episode of hypertension but is not preferred over phenoxybenzamine in pre-operative prevention. Answer 5: Propylthiouracil is used to treat thyroid storm. Although surgery can precipitate thyroid storm in patients with pre-existing thyroid disease, these patients present with hyperthermia, diaphoresis, and tachycardia. Additional treatments for a thyroid storm include intravenous fluids, beta-blockers, and systemic cooling. Bullet Summary: Patients with pheochromocytoma should be medically managed prior to surgery with phenoxybenzamine.
5.0
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