The Quizzes about Trauma, Shock, and Resuscitation – Part 3 (18 test)

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Question 1

A 79-year-old woman with a history of coronary artery disease who underwent a coronary artery bypass graft (CABG) surgery 7 years ago is brought to the emergency department (ED) by her family for 2 days of worsening shortness of For the past 2 days, she has not gotten out of bed and is confused. She does not have chest pain, fevers, or cough. Her temperature is 98.1°F, blood pressure (BP) is 85/50 mm Hg, heart rate (HR) is 125 beats per minute, and respiratory rate (RR) is 26 breaths per minute. On examination, she is unable to follow commands and is oriented only to name. The cardiovascular examination reveals tachycardia with no murmurs. Her lungs have rales bilaterally at the bases. The abdomen is soft, nontender, and nondistended. Lower extremities have 2+ edema to the knee bilaterally. Which of the following is the most likely diagnosis?

A	Hypovolemic shock
B	Neurogenic shock
C	Cardiogenic shock
D	Anaphylactic shock
E	Septic shock

Question 1 Explanation:

This patient is in cardiogenic shock from decreased cardiac output producing inadequate tissue perfusion. Support for this diagnosis includes an older patient with a history of coronary artery disease and new mental status changes coupled with signs of volume overload. Common causes of cardiogenic shock include acute MI, pulmonary embolism, COPD exacerbation, and pneumonia. This patient should be stabilized with IV pressors since there is already pulmonary congestion evident on examination. A rapid workup including ECG, chest x-ray (CXR), laboratory tests, echocardiogram, and hemodynamic monitoring should help confirm the etiology and direct specific treatment of the underlying cause. Hypovolemic shock (a) occurs when there is inadequate volume in the circulatory system, resulting in poor oxygen delivery to the tissues. Neurogenic shock (b) occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Anaphylactic shock (d) is a severe systemic hypersensitivity reaction, resulting in hypotension and airway compromise. Septic shock (e) is a clinical syndrome of hypoperfusion and multiorgan dysfunction caused by infection

Question 2

A 32-year-old man with no past medical problems presents to the ED with For the past 2 days he has been feeling weak and over the last 6 hours he has noticed that his heart is racing. He has no chest pain or shortness of breath. He has never felt this way before. His temperature is 98.9°F, BP is 140/82 mm Hg, HR is 180 beats per minute, and RR is 14 breaths per minute. His physical examination is normal. You obtain the following rhythm strip. What is your first-line treatment for this patient?

A	Synchronized cardioversion at 100 J
B	Adenosine 6-mg intravenous (IV) push
C	Adenosine 12-mg IV push
D	Valsalva maneuver
E	Verapamil 3-mg IV push

Question 2 Explanation:

This patient has supraventricular tachycardia (SVT), a narrow complex, regular tachycardia. It is caused by a reentry or an ectopic pacemaker in areas of the heart above the bundle of His, usually the atria. Regular P waves will be present but may be difficult to discern owing to the very fast rate. The patient in this case has normal vital signs and examination, and is therefore stable. First-line treatment for a patient with stable SVT is vagal maneuvers to slow conduction and prolong the refractory period in the AV node. The Valsalva maneuver can be accomplished by asking the patient to bear down as if they are having a bowel movement and hold the strain for at least 10 seconds. Other vagal maneuvers include carotid sinus massage (after auscultating for carotid bruits) and facial immersion in cold water. If vagal maneuvers fail, the next step is adenosine, a very shortacting AV nodal blocking medication. Initially, adenosine 6 mg (b) is rapidly pushed through the IV in a site as close to the heart as possible. Patients may experience a few seconds of discomfort, including chest pain and facial flushing on receiving the adenosine. If the patient remains inTrauma, Shock, and Resuscitation Answers 161 SVT 2 minutes after receiving adenosine, a second dose of adenosine at 12 mg (c) is administered. If the second dose of adenosine fails and the patient remains stable, short-acting calcium channel blockers (eg, verapamil), (e) β-blockers, or digoxin can be administered. If at any time the patient is considered unstable (hypotension, pulmonary edema, severe chest pain, altered mental status, or other life-threatening concerns), synchronized cardioversion (a) should be performed immediately.

Question 3

You are a passenger aboard an airplane and a 78-year-old woman is complaining of chest pain and difficulty You are the only medical professional available and volunteer to help. Fortunately, the aircraft is well-equipped with basic medical equipment, as well as with ACLS medications and a cardiac monitor. On examination, the passenger’s BP is 75/40 mm Hg, HR is 180 beats per minute, and RR is 24 breaths per minute. On examination, the patient is in obvious distress but able to answer basic questions. Her heart is tachycardic, regular, and without mur- murs, rubs, or gallops. Physical examination is remarkable for a bounding carotid pulse. You attach the cardiac monitor and see a regular rhythm at 180 beats per minute with wide QRS complexes and no obvious P waves. After asking the pilot to make an emergency landing, what do you do next?

A	Amiodarone IV
B	Synchronized cardioversion
C	Verapamil IV
D	Lidocaine IV
E	Procainamide IV

Question 3 Explanation:

Ventricular tachycardia (VT) originates from ectopic ventricular pacemakers and is usually a regular rhythm with rate greater than 100 beats per minute and wide QRS complexes. Treatment of VT is primarily dependent on whether or not the patient is stable. Evidence of acute altered mental status, hypotension, continued chest pain, or other signs of shock are signs of instability. Unstable patients, such as the passenger on this airplane, should receive immediate synchronized cardioversion. It is critical that the cardioverter be placed in the synchronized mode, which permits a search for a large R wave and a corresponding shock around the incidence of such a wave. A shock administered outside of this constraint can induce ventricular fibrillation (VF). Stable patients can be treated with antidysrhythmics. Amiodarone (a) 150 mg IV over 10 minutes is currently first-line treatment as recommended by the American Heart Association (AHA). Lidocaine (d) and procainamide (e) can also be administered. Verapamil (c) should not be used in VT as it may accelerate the HR and cause hypotension.

Question 4

A 41-year-old man is brought into the ED by paramedics in cardio- pulmonary A friend states that the patient is a long-time user of IV heroin. You look at the monitor and see that the patient has pulseless elec- trical activity (PEA). Cardiopulmonary resuscitation is being performed and the patient is intubated. You decide to administer epinephrine to the patient but realize that he does not have IV access. Which of the follow- ing drugs is ineffective when administered through an endotracheal (ET) tube?

A	Atropine
B	Naloxone
C	Lidocaine
D	Epinephrine
E	Sodium bicarbonate

Question 4 Explanation:

Endotracheal administration of drugs is indicated whenever there is a need for emergent pharmacologic intervention in the absence of other access routes, such as IV or intraosseous. There are a limited number of emergency medications that can be administered safely and effectively via the endotracheal route. These include naloxone, atropine, versed, epinephrine, and lidocaine. This is remembered by the mnemonic NAVEL. Specific medications shown to be unsafe include sodium bicarbonate, isoproterenol, and bretylium. The endotracheal dosage of a medication should be at least equivalent to the IV route and is usually 2 to 2.5 times the IV dose administered. The patient in the scenario should receive epinephrine via the ET while IV access is established.

Question 5

A 75-year-old man complaining of chest pain is brought into the ED by He is barely able to speak to you because he is short of breath. The nurse immediately attaches him to the monitor, starts an IV, and gives him oxygen. His temperature is 98.9°F, BP is 70/40 mm Hg, HR is 140 beats per minute, RR is 28 breaths per minute, and oxygen saturation is 95% on room air. On examination, he is in mild distress. His heart is irregular and tachycardic. His lungs are clear to auscultation, with rales at the bases, bilaterally. An electrocardiogram (ECG) is shown below. What is your first-line treatment for this patient?

A	Heparin drip
B	Diltiazem 10-mg IV push
C	Metoprolol 5-mg IV push
D	Digoxin 0.5-mg IV
E	Synchronized cardioversion at 100 J

Question 5 Explanation:

This ECG shows atrial fibrillation with rapid ventricular response (RVR). Normally, one area of the atria depolarizes and causes uniform contraction of the atria. In atrial fibrillation, multiple areas of the atria continuously depolarize and contract, leading to multiple atrial impulses and an irregular ventricular response. Atrial fibrillation reduces the effectiveness of atrial contractions and may lead to or worsen heart failure in patients with left ventricular failure. Treatment of atrial fibrillation is dependent on whether or not the patient is stable or not. This patient is clinically unstable; the atrial fibrillation with RVR has pushed him into heart failure and he is hypotensive and tachypneic. Unstable patients like this should undergo synchronized cardioversion. Synchronized cardioversion is performed at 100 J and then at 200 J if the first attempt fails. The focus of emergency management in stable patients with atrial fibrillation with RVR is ventricular rate control. Diltiazem (b) or verapamil are excellent choices for rate control. Metoprolol (c) or digoxin (d) may also be used, but may depress BP. Recall that patients in atrial fibrillation for longer than 48 hours are at risk for atrial thrombi. If these patients are cardioverted (electrically or chemically), they have a 1% to 2% risk of arterial embolism. Since it is often difficult to determine time of onset, ED patients are generally only cardioverted if they are unstable. Stable patients with atrial fibrillation should be anticoagulated with a loading dose of (a) heparin and oral warfarin for at least 1 month prior to elective cardioversion.

Question 6

A 19-year-old man was struck by a motor vehicle while crossing the street. In the ED, he is awake, alert, and oriented but complaining of severe right leg His temperature is 98.9°F, BP is 85/50 mm Hg, HR is 125 beats per minute, and RR is 24 breaths per minute. You confirm that his airway is patent, breath sounds are equal bilaterally, and his abdomen is soft and nontender. His right leg is shorter than his left leg, slightly angulated, and swollen in his anterior thigh area. There is no open wound. Which of the following is the most likely diagnosis?

A	Hypovolemic shock
B	Neurogenic shock
C	Cardiogenic shock
D	Anaphylactic shock
E	Septic shock

Question 6 Explanation:

This patient is in hypovolemic shock secondary to blood loss from a femoral fracture. Hypovolemic shock occurs when there is inadequate volume in the circulatory system, resulting in poor oxygen delivery to the tissues. Hemorrhage, GI losses, burns, and environmental exposures can all be responsible for hypovolemic shock. In trauma, hemorrhage is the most common cause of hypovolemic shock. This patient fractured his femur, disrupting the nearby vascular supply, resulting in significant blood collection in the soft tissue. This patient’s hypovolemic shock can be treated with aggressive fluid and blood-product replacement. In the meantime, pain control and x-rays of the hip, femur, and knee should be performed. Once the femur fracture is confirmed, a Sager or Hare traction splint should be applied and orthopedics consulted. Other areas of life-threatening hemorrhage in trauma include the chest, abdomen, retroperitoneum, and pelvis. It is also important to keep in mind that significant blood loss could have occurred at the scene despite no obvious active bleeding in the ED.Trauma, Shock, and Resuscitation Answers 163 Neurogenic shock (b) occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Cardiogenic shock (c) is caused by decreased cardiac output producing inadequate tissue perfusion. Anaphylactic shock (d) is a severe systemic hypersensitivity reaction, resulting in hypotension and airway compromise. Septic shock (e) is a clinical syndrome of hypoperfusion and multiorgan dysfunction caused by infection.

Question 7

You are called to the bedside of a hypotensive patient with altered mental status. The nurse hands you an ECG which shows atrial flutter at 150 beats per minute with 2:1 arteriovenous (AV) You feel that the patient is unstable and elect to perform emergency cardioversion. You attach the monitor leads to the patient. What is the critical next step in electrical cardioversion?

A	Set the appropriate energy level.
B	Position conductor pads or paddles on patient.
C	Charge the defibrillator.
D	Turn on the synchronization mode.
E	Administer 25 g of fentanyl IV.

Question 7 Explanation:

Low-energy cardioversion is very successful in converting atrial flutter to sinus rhythm. Remember, cardioversion is different than defibrillation. Cardioversion is performed on patients with organized cardiac electrical activity with pulses, whereas defibrillation is performed on patients without pulses (VF and VF without a pulse). Patients with heart beats who receive electrical energy during their heart’s relative refractory period are at risk for VF. Therefore, cardioversion is a timed shock designed to avoid delivering a shock during the heart’s relative refractory period. By activating synchronization mode, the machine will identify the patient’s R waves and not deliver electrical energy during these times. The key step, when cardioverting, is to activate the synchronization mode and confirm the presence of sync markers on the R waves prior to delivering electrical energy

Question 8

Paramedics bring in a 54-year-old man who was found down in his apartment by his He is successfully intubated in the field and para- medics are currently performing cardiopulmonary resuscitation (CPR). He is transferred to an ED gurney and quickly attached to the cardiac monitors. You ask the paramedics to hold CPR and assess the patient and the rhythm strip. The monitor shows sinus bradycardia, but no pulses are palpable. On examination you appreciate bilateral breath sounds with mechanical ventilation, a soft abdomen, no rashes, and a left arm AV graft. In addition to CPR with epinephrine and atropine every 3 to 5 minutes, which inter- vention should be performed next?

A	Administer 1 ampule of sodium bicarbonate.
B	Administer 1 ampule of calcium gluconate.
C	Administer 1 ampule of D50 (dextrose).
D	Place left-sided chest tube.
E	Perform pericardiocentesis.

Question 8 Explanation:

This patient has cardiac electrical activity (sinus bradycardia) but no detectable pulses. He is therefore in a state of pulseless electrical activity (PEA), and management should be directed by the AHA PEA algorithm. Patients in PEA should be treated with CPR, epinephrine every 3 to 5 minutes, and atropine every 3 to 5 minutes (if PEA rate is < 60 per minute), but a search for an underlying etiology with targeted interventions should still be performed. Common etiologies for PEA are shown in the following table along with their specific treatments. Many find the H’s and T’s in the table an easy way to remember the differential. Each etiology should be considered for every patient with PEA and causes that are more likely given a patient’s history and physical should be treated first. This patient has an AV graft indicating that he has a history of renal disease. Since patients with endstage renal disease are at risk for hyperkalemia and since hyperkalemia can cause PEA, calcium gluconate should be given first to stabilize the cardiac membranes.164 Emergency Medicine PEA Etiologies and Treatments H’s Tx T’s Tx Hypovolemia IV fluids Toxins Antidotes Hypoxia Ventilation Tamponade (cardiac) Pericardiocentesis Hydrogen ion (acidosis) Sodium bicarbonate Tension pneumothorax Tube thoracostomy Hypokalemia and Hypoglycemia KCl, calcium Thrombosis (coronary and Hyperkalemia pulmonary) Thrombolysis Hypoglycemia Dextrose Trauma (hypovolemia and increased ICP) IV fluids Hypothermia Warming If the patient does not improve with calcium, sodium bicarbonate (a) could be given to treat for metabolic acidosis and 50% dextrose (c) can be given for suspected hypoglycemia. Cardiac tamponade is a possible etiology in a patient with renal disease and pericardiocentesis (e) can be attempted if the patient is not improving with the aforementioned treatments. A bedside ultrasound may also be helpful to look for right ventricular collapse or other signs of tamponade. Pneumothorax is a less likely etiology in this particular patient. It is treated with a (d) chest tube.

Question 9

A 72-year-old man is in the ED for the evaluation of generalized weakness over the previous 24 He has a past medical history of coronary artery disease with a CABG performed 5 years ago, diabetes mellitus, and arthritis. The nurse places the patient on a cardiac monitor and begins to get his vital signs. While the nurse is obtaining the vital signs, she notices that the patient suddenly becomes unresponsive. You arrive at the bedside, look at the monitor, and see the following rhythm. Which of the following is the most appropriate next step in management?

A	Wait 5 minutes to see if he awakens on his own.
B	Immediately defibrillate at 200 J (biphasic).
C	Perform synchronized cardioversion at 100 J.
D	Immediately intubate the patient.
E	Insert an IV line and administer amiodarone.

Question 9 Explanation:

The rhythm is VF. Along with pulseless VT, these are nonperfusing rhythms that are treated identically because it is thought to be caused by the same mechanisms. The earlier a “shock” is administered in cardiac arrest, the more likely the patient will return to spontaneous circulation with a perfusing rhythm. If there is a delay to defibrillation (> 4 minutes), CPR should be administered for 60 to 90 seconds before defibrillation. If after defibrillation (200 J biphasic or 360 J monophasic) the patient’s rhythm is still VF or pulseless VT, assisted ventilation and chest compressions should be started. Intubation should be performed and IV access obtained for the administration of epinephrine or vasopressin. If the rhythm is unchanged after administration of vasopressor therapy, another attempt at defibrillation at 360 J (or 200 J biphasic) with subsequent administration of an antidysrhythmic (eg, amiodarone) is recommended. Of note, monophasic defibrillation delivers a charge in only one direction. Biphasic defibrillation delivers a charge in one direction for half of the shock and in the electrically opposite direction for the second half. Biphasic defibrillation significantly decreases the energy necessary for successful defibrillation and decreases the risk of myocardial damage.Trauma, Shock, and Resuscitation Answers 165 (a) There is no role for observation with VF. Successful return of a perfusing rhythm is most likely to result with immediate defibrillation. (c) Synchronized cardioversion is energy delivered to match the QRS complex. This reduces the chance that a shock will induce VF. Synchronization is used to treat tachydysrhythmias (eg, rapid atrial fibrillation) in hemodynamically unstable patients. It should not be used in VF or pulseless VT. (d) The most beneficial intervention for this patient is immediate defibrillation. If this fails, the patient’s airway management (ABCs) will require him to be intubated. (e) Amiodarone, an antidysrhythmic, is used in patients with VF or pulseless VT after appropriate defibrillation and administration of vasopressor therapy

Question 10

An 82-year-old nursing home patient presents to the ED in septic Her BP is 75/40 mm Hg, HR is 117 beats per minute, temperature is 96.5°F, RR is 29 breaths per minute, and oxygen saturation is 87% on room air. As you perform laryngoscopy to intubate the patient, you easily visual- ize the vocal cords and subsequently pass the orotracheal tube through the vocal cords. You place the colorimetric end-tidal carbon dioxide device over the tube and get appropriate color change. There are equal, bilateral breath sounds on auscultation and you observe chest wall motion with ventilation. Which of the following is the most reliable method for verify- ing proper ET tube placement?

A	Chest radiograph
B	Visualization of the ET tube passing through the vocal cords
C	Observation of chest wall motion with ventilation
D	Hearing equal, bilateral breath sounds on auscultation
E	End-tidal carbon dioxide color change

Question 10 Explanation:

The most serious complication of ET intubation is unrecognized esophageal intubation with resultant hypoxic brain injury. Esophageal placement is not always obvious. The best assurance that the tube is placed into the trachea is to see it pass through the vocal cords. (a) The chest radiograph can be misleading and is essentially only useful to identify endobronchial intubation (ie, right main stem bronchus intubation). (c) Although the chest wall should expand with positive pressure and relax with expiration, this may not occur in patients with small tidal volumes or severe bronchospasm. (d) You may hear normal breath sounds if only the midline of the thorax is auscultated. (e) In cardiac arrest situations, low exhaled carbon dioxide levels are seen in both very-lowflow states and in esophageal intubation. In addition, colorimetric changes may be difficult to discern in reduced lighting situations, and secretions can interfere with color change.

Question 11

A 25-year-old man fell off his surfboard and landed on He was pulled from the water by lifeguards and brought to the ED in full cervical and spinal immobilization. He is alert and oriented to person, place, and time. He is complaining of weakness in all of his extremities. His tem- perature is 98.4°F, BP is 85/50 mm Hg, HR is 60 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 98% on room air. On examination, he has no external signs of head injury. His heart is brady- cardic without murmurs. The lungs are clear to auscultation and the abdo- men is soft and nontender. He has grossly normal peripheral sensation but no motor strength in all four extremities. Which of the following is the most likely diagnosis?

A	Hypovolemic shock
B	Neurogenic shock
C	Cardiogenic shock
D	Anaphylactic shock
E	Septic shock

Question 11 Explanation:

This patient is in neurogenic shock. He suffered an acute cervical spine injury after his fall onto rocks and has hypotension and bradycardia. The pathophysiology behind neurogenic shock is still under investigation, but it’s thought to be partially caused by disrupted sympathetic outflow tracts and unopposed vagal tone. Note that all other forms of shock attempt to compensate for hypotension with tachycardia. Neurogenic shock lacks sympathetic innervation; therefore bradycardia results. Given that this is a trauma patient, all other sources for hypotension must be ruled out. He should be treated with cervical spine immobilization and IV fluids. Pressors may be needed if hypotension does not respond to fluids or fluid overload becomes a concern.166 Emergency Medicine Hypovolemic shock (a) occurs when there is inadequate volume in the circulatory system, resulting in poor oxygen delivery to the tissues. Cardiogenic shock (c) is caused by decreased cardiac output producing inadequate tissue perfusion. Anaphylactic shock (d) is a severe systemic hypersensitivity reaction, resulting in hypotension and airway compromise. Septic shock (e) is a clinical syndrome of hypoperfusion, hypotension, or multiorgan dysfunction caused by infection.

Question 12

A 48-year-old man is brought to the ED by paramedics for general- ized His medical history is significant for a CABG last month. He has been unable to get out of bed for the past day because of dizzi- ness when changing position. He denies chest pain, shortness of breath, or syncope. His temperature is 98.9°F, BP is 86/60 mm Hg, HR is 44 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. There is a well-healing midline sternotomy incision. Cardiac examination reveals a III/VI systolic ejection murmur. There are minimal rales at his lung bases. He is immediately attached to the cardiac monitor. His rhythm strip is shown below. What is your initial treatment?

A	Observation on monitor
B	Transcutaneous pacing
C	Transvenous pacing
D	Atropine 0.5 mg IV
E	Epinephrine IV drip at 2 g/minute

Question 12 Explanation:

Atropine is the initial treatment of choice for patients in second-degree, Mobitz I AV block. The majority of patients respond to atropine without further treatment. Mobitz I is commonly seen with acute inferior MI, digoxin toxicity, myocarditis, and after cardiac surgery. Observation alone (a) is appropriate for stable patients. However, this patient is hypotensive and needs more aggressive management. Transcutaneous (eg, electrical pads are placed externally, most commonly on the anterior chest wall) (b) or transvenous (eg, pacing wires are threaded into the right ventricle [RV] through a central vein) pacing (c) is an appropriate treatment and should be attempted if atropine is unsuccessful. Finally, if all else fails, epinephrine (e) or dopamine drips can be started. These treatments should be applied judiciously as the resulting increased HR may worsen patients with active ischemia as the etiology for their bradycardia. Furthermore, patients with acute inferior wall MI may have right ventricular failure and may be hypotensive because of decreased preload, not bradycardia. IV fluids would be the therapy of choice in patients with inferior MI.

Question 13

You are caring for a 54-year-old woman with a history of schizophrenia and coronary artery disease who presents to the ED for chest Her vital signs are within normal limits and her ECG is normal sinus rhythm with nonspecific ST/T-wave changes. Her first troponin is sent to the laboratory and you are planning to admit her to the hospital for a complete acute coronary syndrome (ACS) evaluation. She receives aspirin and nitroglyc- erin and her chest pain resolves. A few minutes later, the nurse alerts you that the patient has become unconscious. You go to the bedside and find the patient awake and alert. You review the rhythm strip below. What is your next step in management?

A	Observation of patient
B	Magnesium sulfate IV
C	Lidocaine IV
D	Transvenous pacemaker
E	Isoproterenol IV

Question 13 Explanation:

This patient had a run of torsade de pointes, an atypical VT where the QRS axis swings from positive to negative within a single ECG lead. This dysrhythmia is frequently seen in patients with significant heart disease who have a prolonged QT interval. There are many possible causes of prolonged QT; however, common etiologies include drugs (eg, antidysrhythmics, psychotropics), electrolyte abnormalities, and coronary heart disease. This patient was likely on a phenothiazine for her schizophrenia leading to prolonged QT syndrome and an episode of torsade de pointes. Administration of magnesium sulfate has been shown to decrease runs of torsades. If the patient has a pulse but his or her vital signs are unstable, you should perform immediate cardioversion.Trauma, Shock, and Resuscitation Answers 167 Observation alone (a), is not adequate. Conventional VT treatments such as lidocaine (c) are often ineffective. Procainamide can actually further prolong the QT interval. If magnesium is unsuccessful, the next strategy involves increasing the HR from 90 to 120 beats per minute, thereby reducing the QT interval and preventing recurrence of torsade de pointes. Increased HR is best achieved by placing a transvenous pacemaker (d); this technique is sometimes called overdrive pacing. During the time it takes for transvenous pacemaker placement, unstable patients can be started on isoproterenol (e), a β-adrenergic receptor agonist to medically increase the HR.

Question 14

A 19-year-old man is brought into the ED by paramedics with a stab wound to the right lower The medics applied a pressure dress- ing and started an IV line en route to the hospital. On arrival, the patient has no complaints and wants to leave. His temperature is 98.4°F, BP is 130/95 mm Hg, HR is 111 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 98% on room air. He is alert and oriented to person, place, and time. His abdomen is soft and nontender, with normal bowel sounds. He has a 2-cm stab wound with visible subcutaneous fat in his right lower quadrant (RLQ). You initiate the FAST examination. Which type of fluid should you start for his initial resuscitation?

A	7% sodium chloride
B	0.9% sodium chloride
C	10% albumin
D	Type and cross-matched blood
E	Type-specific blood

Question 14 Explanation:

Crystalloids such as normal saline (0.9% sodium chloride) or lactated Ringer are the preferred resuscitation fluid in the United States. The patient is currently stable; however, he is tachycardic and has suffered an injury with the potential for significant morbidity. The FAST examination will help illustrate the extent of this patient’s injury. In the meantime, the patient should be started on isotonic crystalloid solution. There is currently no convincing evidence that either solution—normal saline or Ringer lactate—is superior to the other. Hypertonic saline (a) helps prevent the extravascular fluid shift seen with isotonic crystalloids but is volume limited owing to the risk of hypernatremia. Furthermore, clinical studies have not shown clear evidence of improved outcome using hypertonic saline. Colloid solutions (c) such as albumin, FFP, and dextran solutions have larger protein components and would therefore be expected to remain in the intravascular space. However, this is a theoretical benefit, as numerous studies have not shown improved outcome using colloid solutions. Blood (d and e) is the best resuscitation fluid. Cross-matched blood is preferred over type-specific blood, if time is available to perform the cross-match. In this case, the patient has only minimal tachycardia. He can receive crystalloid first with continuous monitoring while the diagnostic workup continues. Blood is indicated after 2 to 3 L of crystalloid infusion and only minimal improvement in vital signs or when the patient has obviously suffered significant blood loss.

Question 15

An 82-year-old man with a history of COPD and hypertension pres- ents with shortness of breath and His medications include albuterol, ipratropium, prednisone, hydrochlorothiazide, and atenolol. His tempera- ture is 102.1°F, BP is 70/40 mm Hg, HR is 110 beats per minute, RR is 24 breaths per minute, and oxygen saturation is 91% on room air. The patient is uncomfortable and mumbling incoherently. On chest examina- tion, you appreciate rales on the left side of his chest. His heart is tachy- cardic, but regular with no murmurs, rubs, or gallops. His abdomen is soft and nontender. You believe this patient is in septic shock from pneumonia and start IV fluids, broad-spectrum antibiotics, and a dopamine drip. His BP remains at 75/50 mm Hg. Which of the following is the most appropri- ate next step in management?

A	D5 normal saline IV bolus
B	Phenylephrine IV drip
C	Fludrocortisone IV
D	Hydrocortisone IV
E	Epinephrine IV drip

Question 15 Explanation:

This patient is in septic shock from pneumonia and also has adrenal crisis. Initial treatment with IV fluids, antibiotics, and dopamine is appropriate. Continued hypotension in a patient on maintenance steroid therapy should make you think of adrenal crisis. Exogenous glucocorticoids suppress hypothalamic release168 Emergency Medicine of corticotropin-releasing hormone (CRH) and subsequently anterior pituitary release of adrenocorticotropic hormone (ACTH). The adrenals subsequently atrophy from lack of stimulation. The patient is now faced with an acute stress from pneumonia and sepsis. His adrenals have atrophied and are unable to respond with increased cortisol secretion. Laboratory clues to adrenal crisis include hyponatremia and hyperkalemia caused by a lack of aldosterone. The treatment of adrenal crisis in the face of septic shock is hydrocortisone. Mineralocorticoids, such as fludrocortisone (c), are not needed. Additional fluids (a) and pressors (b and e) are appropriate critical care management for sepsis and should be administered after glucocorticoids.

Question 16

A 64-year-old woman with a history of depression and hypertension was found down by her husband and brought in by the Her husband says that she has recently been depressed and expressed thoughts of suicide. She usually takes fluoxetine for depression and atenolol for hypertension. On arrival, the patient is obtunded, but responds to pain and is maintaining her airway. Her temperature is 98.1°F, BP is 70/40 mm Hg, HR is 42 beats per minute, RR is 12 breaths per minute, and oxygen saturation is 94% on room air. On examination, her pupils are 3 mm and reactive bilaterally. Lungs are clear to auscultation. Heart is bradycardic, but regular, with no murmurs, rubs, or gallops. Extremities have no edema. An ECG shows first-degree AV block at 42 beats per minute, but no ST/T- wave changes. Blood sugar is 112 mg/dL. What is the most specific treat- ment for this patient’s ingestion?

A	Fluid bolus
B	Atropine
C	Glucagon
D	Epinephrine
E	Cardiac pacing

Question 16 Explanation:

Toxic ingestions must always be considered, especially in suicidal patients. The patient regularly takes atenolol for hypertension and may have overdosed on this occasion. a-Blocker toxicity classically causes bradycardia and hypotension. Antidotes for β-blocker toxicity, such as glucagon, should be given to this patient immediately. Glucagon is thought to work through a separate receptor that is not blocked by β-adrenergic antagonists, ultimately enhancing inotropy and chronotropy. Patents who are hypotensive should receive intravenous fluids (normal saline) and be administered pressor agents, such as norepinephrine. Other medications that may be useful are phosphodiesterase inhibitors (eg, milrinone), which block cyclic adenosine monophosphate (cAMP) breakdown and maintain intracellular calcium levels. High-dose insulin is a promising treatment for β-blocker toxicity. Ultimately, the patient may require the other treatment options, but glucagon should be the first-line therapy. You should administer an IV bolus of fluids (a), you may attempt to administer atropine (b), and place external cardiac pacers on the patient (e). However, because this is a β-blocker overdose, the administration of glucagon should treat the patient. (d) Epinephrine should be administered if the patient loses his pulse.

Question 17

A 19-year-old man suffers a single gunshot wound to the left chest and is brought in by his He is complaining of chest pain. On exam- ination, his temperature is 99°F, BP is 70/40 mm Hg, HR is 140 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 96% on room air. He has distended neck veins, but his trachea is not deviated. Lungs are clear to auscultation bilaterally. Heart sounds are difficult to appreciate, but you feel a bounding, regular pulse. Abdomen is soft and nontender. Extremity examination is normal. Two large-bore IV lines are placed and the patient is given 2 L of normal saline. Chest radiograph shows a globular cardiac silhouette but a normal mediastinum and no pneumothorax. What is the definitive management of this patient?

A	Intubation
B	Tube thoracostomy
C	Pericardiocentesis
D	Thoracotomy
E	Blood transfusion

Question 17 Explanation:

Patients with penetrating trauma to the chest with possible cardiac injury and signs of hemodynamic instability need immediate operative thoracotomy. This patient has signs of cardiac tamponade, a collection of blood surrounding the heart and interfering with the heart’s ability to contract. He has Beck triad of hypotension, distended neck veins, and muffled heart sounds. His CXR also showsTrauma, Shock, and Resuscitation Answers 169 an enlarged heart. An echocardiogram would be helpful in confirming the diagnosis, but, since this patient is unstable and echocardiogram may not be readily available, the treatment is immediate thoracotomy in the operating room. While pericardiocentesis (c) may help relieve tamponade, it is not the optimal procedure for traumatic tamponade. Pericardiocentesis may be difficult when clots fill the pericardium and may therefore give false-negative results. The procedure may also injure the heart and delay definitive treatment. Some clinicians perform bilateral tube thoracostomy (b) prior to thoracotomy to rule out a hemo- and pneumothorax. However, with equal breath sounds, midline trachea, and no evidence of pneumothorax or consolidation on radiograph, chest tubes are low yield in this patient. The patient is not in respiratory distress. Intubation (a) should be performed in the OR to prevent additional delays in definitive surgical care. IV fluids and blood transfusion (e) increase venous return to the heart and are excellent supportive measures prior to definitive thoracotomy

Question 18

An 87-year-old woman with a history of dementia, arthritis, and hypertension presents to the ED for abdominal Her caretaker reports that she is having mid-epigastric pain and had one episode of nonbloody, nonbilious vomiting prior to arrival. The patient is oriented to name only. Temperature is 99.8°F, HR is 110 beats per minute, BP is 80/44 mm Hg, RR is 16 breaths per minute, and oxygen saturation is 96% on room air. On examination, the abdomen is soft, nontender, with no masses, rebound or guarding. Stool is brown and guaiac negative. You place two IV lines and begin fluid resuscitation. You send her blood to the laboratory and order a radiograph of her chest that is shown below. Which of the following is the most appropriate next step in management?

A	Start IV antibiotics.
B	Order a CT scan of her abdomen.
C	Call the surgery service.
D	Place a central venous line.
E	Discharge home with Maalox.

Question 18 Explanation:

Abdominal pain in the elderly can be challenging for many reasons, including poor histories and deviation from classic presentations of diseases. However, abdominal pain in patients over 65 must be taken seriously since 25% to 44% require surgical intervention and more than 50% require admission to the hospital. This CXR reveals free air under the right diaphragm, likely from a perforated viscous. This is a surgical emergency and the surgical service should be contacted. Antibiotics (a) and a central venous line (d) are appropriate and can be started after the surgical team has been notified. It is important to obtain large-bore IV access for this patient. If peripheral lines are not obtained, a central venous line should be inserted. A CT scan (b) is not necessary in this patient, especially with her low BP. She should be taken directly to the OR for an exploratory laparotomy. Although the patient has a benign abdominal examination, the caretakers report and her low BP is worrisome and sending the patient home (e) prior to a complete workup would be a mistake.

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1. A 79-year-old woman with a history of coronary artery disease who underwent a coronary artery bypass graft (CABG) surgery 7 years ago is brought to the emergency department (ED) by her family for 2 days of worsening shortness of For the past 2 days, she has not gotten out of bed and is confused. She does not have chest pain, fevers, or cough. Her temperature is 98.1°F, blood pressure (BP) is 85/50 mm Hg, heart rate (HR) is 125 beats per minute, and respiratory rate (RR) is 26 breaths per minute. On examination, she is unable to follow commands and is oriented only to name. The cardiovascular examination reveals tachycardia with no murmurs. Her lungs have rales bilaterally at the bases. The abdomen is soft, nontender, and nondistended. Lower extremities have 2+ edema to the knee bilaterally. Which of the following is the most likely diagnosis?

Hypovolemic shock
Neurogenic shock
Cardiogenic shock
Anaphylactic shock
Septic shock

2. A 32-year-old man with no past medical problems presents to the ED with For the past 2 days he has been feeling weak and over the last 6 hours he has noticed that his heart is racing. He has no chest pain or shortness of breath. He has never felt this way before. His temperature is 98.9°F, BP is 140/82 mm Hg, HR is 180 beats per minute, and RR is 14 breaths per minute. His physical examination is normal. You obtain the following rhythm strip. What is your first-line treatment for this patient?

Synchronized cardioversion at 100 J
Adenosine 6-mg intravenous (IV) push
Adenosine 12-mg IV push
Valsalva maneuver
Verapamil 3-mg IV push

3. You are a passenger aboard an airplane and a 78-year-old woman is complaining of chest pain and difficulty You are the only medical professional available and volunteer to help. Fortunately, the aircraft is well-equipped with basic medical equipment, as well as with ACLS medications and a cardiac monitor. On examination, the passenger’s BP is 75/40 mm Hg, HR is 180 beats per minute, and RR is 24 breaths per minute. On examination, the patient is in obvious distress but able to answer basic questions. Her heart is tachycardic, regular, and without mur- murs, rubs, or gallops. Physical examination is remarkable for a bounding carotid pulse. You attach the cardiac monitor and see a regular rhythm at 180 beats per minute with wide QRS complexes and no obvious P waves. After asking the pilot to make an emergency landing, what do you do next?

Amiodarone IV
Synchronized cardioversion
Verapamil IV
Lidocaine IV
Procainamide IV

4. A 41-year-old man is brought into the ED by paramedics in cardio- pulmonary A friend states that the patient is a long-time user of IV heroin. You look at the monitor and see that the patient has pulseless elec- trical activity (PEA). Cardiopulmonary resuscitation is being performed and the patient is intubated. You decide to administer epinephrine to the patient but realize that he does not have IV access. Which of the follow- ing drugs is ineffective when administered through an endotracheal (ET) tube?

Atropine
Naloxone
Lidocaine
Epinephrine
Sodium bicarbonate

5. A 75-year-old man complaining of chest pain is brought into the ED by He is barely able to speak to you because he is short of breath. The nurse immediately attaches him to the monitor, starts an IV, and gives him oxygen. His temperature is 98.9°F, BP is 70/40 mm Hg, HR is 140 beats per minute, RR is 28 breaths per minute, and oxygen saturation is 95% on room air. On examination, he is in mild distress. His heart is irregular and tachycardic. His lungs are clear to auscultation, with rales at the bases, bilaterally. An electrocardiogram (ECG) is shown below. What is your first-line treatment for this patient?

Heparin drip
Diltiazem 10-mg IV push
Metoprolol 5-mg IV push
Digoxin 0.5-mg IV
Synchronized cardioversion at 100 J

6. A 19-year-old man was struck by a motor vehicle while crossing the street. In the ED, he is awake, alert, and oriented but complaining of severe right leg His temperature is 98.9°F, BP is 85/50 mm Hg, HR is 125 beats per minute, and RR is 24 breaths per minute. You confirm that his airway is patent, breath sounds are equal bilaterally, and his abdomen is soft and nontender. His right leg is shorter than his left leg, slightly angulated, and swollen in his anterior thigh area. There is no open wound. Which of the following is the most likely diagnosis?

Hypovolemic shock
Neurogenic shock
Cardiogenic shock
Anaphylactic shock
Septic shock

7. You are called to the bedside of a hypotensive patient with altered mental status. The nurse hands you an ECG which shows atrial flutter at 150 beats per minute with 2:1 arteriovenous (AV) You feel that the patient is unstable and elect to perform emergency cardioversion. You attach the monitor leads to the patient. What is the critical next step in electrical cardioversion?

Set the appropriate energy level.
Position conductor pads or paddles on patient.
Charge the defibrillator.
Turn on the synchronization mode.
Administer 25 mg of fentanyl IV.

8. Paramedics bring in a 54-year-old man who was found down in his apartment by his He is successfully intubated in the field and para- medics are currently performing cardiopulmonary resuscitation (CPR). He is transferred to an ED gurney and quickly attached to the cardiac monitors. You ask the paramedics to hold CPR and assess the patient and the rhythm strip. The monitor shows sinus bradycardia, but no pulses are palpable. On examination you appreciate bilateral breath sounds with mechanical ventilation, a soft abdomen, no rashes, and a left arm AV graft. In addition to CPR with epinephrine and atropine every 3 to 5 minutes, which inter- vention should be performed next?

Administer 1 ampule of sodium bicarbonate.
Administer 1 ampule of calcium gluconate.
Administer 1 ampule of D50 (dextrose).
Place left-sided chest tube.
Perform pericardiocentesis.

9. A 72-year-old man is in the ED for the evaluation of generalized weakness over the previous 24 He has a past medical history of coronary artery disease with a CABG performed 5 years ago, diabetes mellitus, and arthritis. The nurse places the patient on a cardiac monitor and begins to get his vital signs. While the nurse is obtaining the vital signs, she notices that the patient suddenly becomes unresponsive. You arrive at the bedside, look at the monitor, and see the following rhythm. Which of the following is the most appropriate next step in management?

Wait 5 minutes to see if he awakens on his own.
Immediately defibrillate at 200 J (biphasic).
Perform synchronized cardioversion at 100 J.
Immediately intubate the patient.
Insert an IV line and administer amiodarone.

10. An 82-year-old nursing home patient presents to the ED in septic Her BP is 75/40 mm Hg, HR is 117 beats per minute, temperature is 96.5°F, RR is 29 breaths per minute, and oxygen saturation is 87% on room air. As you perform laryngoscopy to intubate the patient, you easily visual- ize the vocal cords and subsequently pass the orotracheal tube through the vocal cords. You place the colorimetric end-tidal carbon dioxide device over the tube and get appropriate color change. There are equal, bilateral breath sounds on auscultation and you observe chest wall motion with ventilation. Which of the following is the most reliable method for verify- ing proper ET tube placement?

Chest radiograph
Visualization of the ET tube passing through the vocal cords
Observation of chest wall motion with ventilation
Hearing equal, bilateral breath sounds on auscultation
End-tidal carbon dioxide color change

11. A 25-year-old man fell off his surfboard and landed on He was pulled from the water by lifeguards and brought to the ED in full cervical and spinal immobilization. He is alert and oriented to person, place, and time. He is complaining of weakness in all of his extremities. His tem- perature is 98.4°F, BP is 85/50 mm Hg, HR is 60 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 98% on room air. On examination, he has no external signs of head injury. His heart is brady- cardic without murmurs. The lungs are clear to auscultation and the abdo- men is soft and nontender. He has grossly normal peripheral sensation but no motor strength in all four extremities. Which of the following is the most likely diagnosis?

Hypovolemic shock
Neurogenic shock
Cardiogenic shock
Anaphylactic shock
Septic shock

12. A 48-year-old man is brought to the ED by paramedics for general- ized His medical history is significant for a CABG last month. He has been unable to get out of bed for the past day because of dizzi- ness when changing position. He denies chest pain, shortness of breath, or syncope. His temperature is 98.9°F, BP is 86/60 mm Hg, HR is 44 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. There is a well-healing midline sternotomy incision. Cardiac examination reveals a III/VI systolic ejection murmur. There are minimal rales at his lung bases. He is immediately attached to the cardiac monitor. His rhythm strip is shown below. What is your initial treatment?

Observation on monitor
Transcutaneous pacing
Transvenous pacing
Atropine 0.5 mg IV
Epinephrine IV drip at 2 mg/minute

13. You are caring for a 54-year-old woman with a history of schizophrenia and coronary artery disease who presents to the ED for chest Her vital signs are within normal limits and her ECG is normal sinus rhythm with nonspecific ST/T-wave changes. Her first troponin is sent to the laboratory and you are planning to admit her to the hospital for a complete acute coronary syndrome (ACS) evaluation. She receives aspirin and nitroglyc- erin and her chest pain resolves. A few minutes later, the nurse alerts you that the patient has become unconscious. You go to the bedside and find the patient awake and alert. You review the rhythm strip below. What is your next step in management?

Observation of patient
Magnesium sulfate IV
Lidocaine IV
Transvenous pacemaker
Isoproterenol IV

14. A 19-year-old man is brought into the ED by paramedics with a stab wound to the right lower The medics applied a pressure dress- ing and started an IV line en route to the hospital. On arrival, the patient has no complaints and wants to leave. His temperature is 98.4°F, BP is 130/95 mm Hg, HR is 111 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 98% on room air. He is alert and oriented to person, place, and time. His abdomen is soft and nontender, with normal bowel sounds. He has a 2-cm stab wound with visible subcutaneous fat in his right lower quadrant (RLQ). You initiate the FAST examination. Which type of fluid should you start for his initial resuscitation?

7% sodium chloride
0.9% sodium chloride
10% albumin
Type and cross-matched blood
Type-specific blood

15. An 82-year-old man with a history of COPD and hypertension pres- ents with shortness of breath and His medications include albuterol, ipratropium, prednisone, hydrochlorothiazide, and atenolol. His tempera- ture is 102.1°F, BP is 70/40 mm Hg, HR is 110 beats per minute, RR is 24 breaths per minute, and oxygen saturation is 91% on room air. The patient is uncomfortable and mumbling incoherently. On chest examina- tion, you appreciate rales on the left side of his chest. His heart is tachy- cardic, but regular with no murmurs, rubs, or gallops. His abdomen is soft and nontender. You believe this patient is in septic shock from pneumonia and start IV fluids, broad-spectrum antibiotics, and a dopamine drip. His BP remains at 75/50 mm Hg. Which of the following is the most appropri- ate next step in management?

D5 normal saline IV bolus
Phenylephrine IV drip
Fludrocortisone IV
Hydrocortisone IV
Epinephrine IV drip

16. A 64-year-old woman with a history of depression and hypertension was found down by her husband and brought in by the Her husband says that she has recently been depressed and expressed thoughts of suicide. She usually takes fluoxetine for depression and atenolol for hypertension. On arrival, the patient is obtunded, but responds to pain and is maintaining her airway. Her temperature is 98.1°F, BP is 70/40 mm Hg, HR is 42 beats per minute, RR is 12 breaths per minute, and oxygen saturation is 94% on room air. On examination, her pupils are 3 mm and reactive bilaterally. Lungs are clear to auscultation. Heart is bradycardic, but regular, with no murmurs, rubs, or gallops. Extremities have no edema. An ECG shows first-degree AV block at 42 beats per minute, but no ST/T- wave changes. Blood sugar is 112 mg/dL. What is the most specific treat- ment for this patient’s ingestion?

Fluid bolus
Atropine
Glucagon
Epinephrine
Cardiac pacing

17. A 19-year-old man suffers a single gunshot wound to the left chest and is brought in by his He is complaining of chest pain. On exam- ination, his temperature is 99°F, BP is 70/40 mm Hg, HR is 140 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 96% on room air. He has distended neck veins, but his trachea is not deviated. Lungs are clear to auscultation bilaterally. Heart sounds are difficult to appreciate, but you feel a bounding, regular pulse. Abdomen is soft and nontender. Extremity examination is normal. Two large-bore IV lines are placed and the patient is given 2 L of normal saline. Chest radiograph shows a globular cardiac silhouette but a normal mediastinum and no pneumothorax. What is the definitive management of this patient?

Intubation
Tube thoracostomy
Pericardiocentesis
Thoracotomy
Blood transfusion

18. An 87-year-old woman with a history of dementia, arthritis, and hypertension presents to the ED for abdominal Her caretaker reports that she is having mid-epigastric pain and had one episode of nonbloody, nonbilious vomiting prior to arrival. The patient is oriented to name only. Temperature is 99.8°F, HR is 110 beats per minute, BP is 80/44 mm Hg, RR is 16 breaths per minute, and oxygen saturation is 96% on room air. On examination, the abdomen is soft, nontender, with no masses, rebound or guarding. Stool is brown and guaiac negative. You place two IV lines and begin fluid resuscitation. You send her blood to the laboratory and order a radiograph of her chest that is shown below. Which of the following is the most appropriate next step in management?

Start IV antibiotics.
Order a CT scan of her abdomen.
Call the surgery service.
Place a central venous line.
Discharge home with Maalox.

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