Shock And Resuscitation (1 - 6 Of 13 MCQs)

1. A 29-year-old woman with no known medical problems is having dinner with her husband. Halfway through dinner, she begins scratching her arms and her husband notices that her face is flushed. The itching intensifies and she begins to feel chest pain, shortness of breath, and dizziness. On arrival to the emergency, she can barely talk. Her temperature is 100⁰ F, BP is 85/50 mm Hg, HR is 125 beats per minute, and RR is 26 breaths per minute, and oxygen saturation is 91% on room air. What is the most likely diagnosis?

Hypovolemic shock

Neurogenic shock

Cardiogenic shock

Anaphylactic shock

Septic shock

This patient is in anaphylactic shock from a food allergy while dining. Anaphylaxis is a severe systemic hypersensitivity reaction leading to shock from hypotension and respiratory compromise. The diagnosis is made clinically: This patient's reaction began classically with urticarial symptoms of pruritus and flushing. She then progressed to shock with hypotension and respiratory edema. She should be treated immediately with oxygen, intramuscular or IV epinephrine, corticosteroids, diphenhydramine, and IV fluids.

For more visit www.rimemcq.com

Explanation

This patient is in anaphylactic shock from a food allergy while dining. Anaphylaxis is a severe systemic hypersensitivity reaction leading to shock from hypotension and respiratory compromise. The diagnosis is made clinically: This patient's reaction began classically with urticarial symptoms of pruritus and flushing. She then progressed to shock with hypotension and respiratory edema. She should be treated immediately with oxygen, intramuscular or IV epinephrine, corticosteroids, diphenhydramine, and IV fluids.

For more visit www.rimemcq.com

2. A 67-year-old woman with coronary artery disease had a coronary artery bypass graft surgery 10 years back. Now, she is brought to the emergency with worsening shortness of breath of 2 days duration. For the past 2 days, she has not gotten out to bed and is confused. She does not have chest pain or cough. Her temperature is 98.1 F. Her blood pressure is 85/50 mm Hg, heart rate is 125 beats per minute and respiratory rate 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 murmur. Her lungs have rales bilaterally at the bases. The abdomen is soft, nontender, and not distended. Lower extremities have 2+ edema bilaterally. What is the diagnosis?

Hypovolemic shock

Neurogenic shock

Cardiogenic shock

Anaphylactic shock

Septic shock

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, new mental status changes, dyspnea, edema and basal crepitations. Common causes of cardiogenic shock include acute MI, pulmonary embolism, COPD exacerbation, and pneumonia. A rapid workup including ECG, chest x-ray, laboratory tests, echocardiogram, and hemodynamic monitoring should confirm the etiology.

Hypovolemic shock occurs when there is inadequate volume in the circulatory system, resulting in poor oxygen delivery to the tissues. Neurogenic shock occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Anaphylactic shock is a severe systemic hypersensitivity reaction resulting in hypotension and airway compromise. Septic shock is a clinical syndrome of hypoperfusion and multiorgan dysfunction caused by infection.

For more visit www.rimemcq.com

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, new mental status changes, dyspnea, edema and basal crepitations. Common causes of cardiogenic shock include acute MI, pulmonary embolism, COPD exacerbation, and pneumonia. A rapid workup including ECG, chest x-ray, laboratory tests, echocardiogram, and hemodynamic monitoring should confirm the etiology.

Hypovolemic shock occurs when there is inadequate volume in the circulatory system, resulting in poor oxygen delivery to the tissues. Neurogenic shock occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Anaphylactic shock is a severe systemic hypersensitivity reaction resulting in hypotension and airway compromise. Septic shock is a clinical syndrome of hypoperfusion and multiorgan dysfunction caused by infection.

For more visit www.rimemcq.com

3. A 21-year-old man was struck by a motor vehicle while crossing the street. In the emergency, he is awake, alert, and oriented, but complaining of severe right-leg pain. 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. 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. What is the most likely diagnosis?

Hypovolemic shock

Neurogenic shock

Cardiogenic shock

Anaphylactic shock

Septic shock

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.

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 emergency.

Neurogenic shock Occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Cardiogenic shock is caused by decreased cardiac output producing inadequate tissue perfusion. Anaphylactic shock is a severe systemic hypersensitivity reaction resulting in hypotension and airway compromise. Septic shock is a clinical syndrome of hypoperfusion and multiorgan dysfunction caused by infection.

For more visit www.rimemcq.com

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.

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 emergency.

Neurogenic shock Occurs after an acute spinal cord injury, which disrupts sympathetic innervation resulting in hypotension and bradycardia. Cardiogenic shock is caused by decreased cardiac output producing inadequate tissue perfusion. Anaphylactic shock is a severe systemic hypersensitivity reaction resulting in hypotension and airway compromise. Septic shock is a clinical syndrome of hypoperfusion and multiorgan dysfunction caused by infection.

For more visit www.rimemcq.com

4. A 70-year-old man is talking incoherently and not eating at his home. He has a past medical history of hypertension, diabetes, dementia, and benign prostatic hypertrophy. On arrival to the hospital, the patient is oriented only to name. His temperature is 101°F rectally, BP is 85/50 mm Hg, HR is 125 beats per minute, RR is 22 breaths per minute, and blood sugar is 154 mg/dL. He appears uncomfortable and cachectic. His lungs are clear to auscultation, with scant crackles at the bases. His abdomen is soft, nontender and not distended. He has a Foley catheter in place draining cloudy, white urine. He has no peripheral edema. What is the most likely diagnosis?

Hypovolemic shock

Neurogenic shock

Cardiogenic shock

Anaphylactic shock

Septic shock

Septic shock is a clinical syndrome of hypoperfusion, hypotension, and multiorgan dysfunction caused by infection. This patient is clearly in shock with hypotension, tachycardia, tachypnea, and acute mental status changes. He also has fever and pus in his urine, making a urine infection the likely source of infection. Elderly patients with comorbid conditions, such as diabetes are more prone to developing sepsis. In addition, patients with indwelling lines, such as Foley catheters, are at an even higher risk for infection.

For more visit www.rimemcq.com

Explanation

Septic shock is a clinical syndrome of hypoperfusion, hypotension, and multiorgan dysfunction caused by infection. This patient is clearly in shock with hypotension, tachycardia, tachypnea, and acute mental status changes. He also has fever and pus in his urine, making a urine infection the likely source of infection. Elderly patients with comorbid conditions, such as diabetes are more prone to developing sepsis. In addition, patients with indwelling lines, such as Foley catheters, are at an even higher risk for infection.

For more visit www.rimemcq.com

5. A 73-year-old man is in the emergency for the evaluation of generalized weakness over the previous 24 hours. 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. The patient suddenly becomes unresponsive. You arrive at the bedside and see the rhythm shown below. Which is the next step in management?

Wait 5 minutes to see if he awakens on his own

Immediately defibrillate at 200 J

Perform synchronized cardioversion at 100

Immediately intubate the patient

Insert an IV line and administer amiodarone

The rhythm shown is VF. The earlier a "shock" is administered in cardiac arrest, the more likely the patient will return to spontaneous circulation. If there is a delay to defibrillation (> 4 minutes), CPR should be administered for 60 to 90 seconds before defibrillation. If after defibrillation, the patient rhythm is still VF or pulseless VT, then 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, then another attempt at defibrillation with subsequent administration of amiodarone is recommended.

There is no role for observation with VF. Successful return of a perfusing rhythm is most likely to result with immediate defibrillation. 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 tachyarrhythmias (eg, rapid atrial fibrillation) in hemodynamically unstable patients. It should not be used in VF or pulseless VT.

Amiodarone is used in patients with VF or pulse less VT after appropriate defibrillation and administration of vasopressor therapy.

For more visit www.rimemcq.com

Explanation

The rhythm shown is VF. The earlier a "shock" is administered in cardiac arrest, the more likely the patient will return to spontaneous circulation. If there is a delay to defibrillation (> 4 minutes), CPR should be administered for 60 to 90 seconds before defibrillation. If after defibrillation, the patient rhythm is still VF or pulseless VT, then 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, then another attempt at defibrillation with subsequent administration of amiodarone is recommended.

There is no role for observation with VF. Successful return of a perfusing rhythm is most likely to result with immediate defibrillation. 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 tachyarrhythmias (eg, rapid atrial fibrillation) in hemodynamically unstable patients. It should not be used in VF or pulseless VT.

Amiodarone is used in patients with VF or pulse less VT after appropriate defibrillation and administration of vasopressor therapy.

For more visit www.rimemcq.com

6. A 31-year-old man with no past medical problems presents to the emergency with palpitations. 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. The ECG is given below. What is your first-line treatment for this patient?

Synchronized cardioversion at 100 J

Adenosine 6-mg IV push

Adenosine 12-mg IV push

Valsalva maneuver

Verapamil 3-mg IV push

The ECG shows a narrow complex, regular tachycardia typical of supraventricular tachycardia. It is caused by a re-entry 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. 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 short-acting AV nodal blocking medication. Initially, adenosine 6 mg 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 in SVT 2 minutes after receiving adenosine, a second dose of adenosine at 12 mg is administered. If the second dose of adenosine fails and the patient remains stable, short-acting calcium channel blockers (eg, verapamil), beta-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 should be performed immediately.

For more visit www.rimemcq.com

Explanation

The ECG shows a narrow complex, regular tachycardia typical of supraventricular tachycardia. It is caused by a re-entry 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. 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 short-acting AV nodal blocking medication. Initially, adenosine 6 mg 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 in SVT 2 minutes after receiving adenosine, a second dose of adenosine at 12 mg is administered. If the second dose of adenosine fails and the patient remains stable, short-acting calcium channel blockers (eg, verapamil), beta-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 should be performed immediately.

For more visit www.rimemcq.com