Cardiovascular Critical Care II

patients for whom the information is unknown, clinical

evaluation and attainment of information should occur,

when possible. This retrieval of information, together

with the administration of medications and advanced

airway placement, should never impede on the provision

of CPR or defibrillation, if indicated, because defibrilla-

tion (for VF and pVT)) and CPR are the only strategies

that have been shown to affect survival from cardiac

arrest (Answer A is incorrect). Pulseless electrical

activity is not a wide complex dysrhythmia, and defibril-

lation would not be indicated (Answer C is incorrect).

Post-cardiac arrest care is crucial in the prevention of

re-arrest and, in temperature control, can significantly

affect neurologic outcomes (Answer D is incorrect).

Answer: D

In general, it is important to remember that medication

administration benefits only myocardial blood flow,

ROSC, and possibly survival to hospital admission in

cardiac arrest. Medication administration should never

impede the provision of CPR and/or defibrillation.

Central administration, if already available, is preferred

for several reasons. These include higher peak concen-

trations, shorter circulation time, more standard dosing,

and the lack of additional administration techniques

needed (Answer D is correct). Endotracheal administra-

tion is an option, but only NAVEL (naloxone, atropine,

vasopressin, epinephrine, and lidocaine) medications

can be administered, the optimal doses are unknown,

and medications must be diluted before administered

(Answer A is incorrect). Given that this patient is in VF

arrest, amiodarone, for example, could not be adminis-

tered by endotracheal administration if it were indicated.

Peripheral administration can be used and is the most

common route of administration given that most hospital-

ized patients have it already, but it requires an additional

bolus of fluid afterward and has a longer circulating time

than does central administration (Answer B is incor-

rect). Intraosseous can also be used, with the caveat that

tibial intraosseous administration is similar to peripheral

administration and requires training to master the tech-

nique for placement (Answer C is incorrect).

Answer: B

Temperature control improves neurologic recovery

when initiated, optimally within 2 hours but in up to 6–8

hours after VF cardiac arrest (application to all forms),

and used for 12–24 hours (Answer C is incorrect). The

goal temperature is 32°C–36°C. Data suggest there is

no benefit of 33°C versus 36°C in improvement of sur-

vival or neurologic outcomes (Answer D is incorrect).

If temperature control will be used, close monitoring

of complications should occur. These complications

include hyperglycemia caused by decreased insulin

production and peripheral activity (Answer A is incor-

rect), bradycardias, enzymatic slowing (including CYP

system), increased incidence of sepsis and infections,

coagulopathies, decreased glomerular filtration, and

shivering (Answer B is correct).

Answer: D

This patient is experiencing a hypertensive emergency

with his target organ damage being an acute aortic

dissection. Aortic dissection is one of the individual

hypertensive emergencies that has a specific mechanism

of worsening (propagation) from BP and shear stress,

which require both rapid BP and HR control. Given the

gravity of propagation, goals for aortic dissection are HR

less than 60 beats/minute and SBP less than 100 mm Hg

within minutes, if possible (Answer A is incorrect). This

can be accomplished with a single agent like labetalol,

which will control HR with its β-antagonist properties

and decrease BP (afterload) with its α-antagonist proper-

ties (Answers B and C are incorrect). Esmolol can also

be used as first line but will likely require an additional

afterload-reducing agent such as nitroprusside (Answer

D is correct).