Cardiovascular Critical Care II

Answer: C

The largest portion of adult cardiac arrests are caused

by cardiovascular, not respiratory, events (Answer A

is incorrect). In addition, this patient was on room air

immediately before the event, which could suggest his

respiratory status was stable and unlikely to lead to car-

diac arrest. Advanced airways and medications have

only been shown to facilitate ROSC in cardiac arrest

in contrast to chest compressions and defibrillation (if

indicated), which can improve survival. Because of this,

CPR should begin immediately for this patient before

line placement to facilitate medication delivery (Answer

B is incorrect), starting with chest compressions in

accordance with the BLS guidelines with pads placed

simultaneously to facilitate rapid defibrillation if the

patient’s rhythm reveals a shockable rhythm (Answer C

is correct; Answer D is incorrect).

The cornerstone of therapy for VF cardiac arrest is rapid

defibrillation (Answer A is correct). The recommended

dosage of voltage for biphasic defibrillators is 200 J or

the manufacturer’s recommendation (often the same dos-

age). Although amiodarone is in the treatment algorithm

for VF cardiac arrest, it is reserved and recommended

for refractory VF cardiac arrest, which is defined as defi-

brillation refractory (Answer B is incorrect). Therefore,

defibrillation should occur first. Atropine has been

removed from the cardiac arrest algorithms for PEA and

asystole because of a lack of benefit on outcomes and

should not be considered for VF cardiac arrest (Answer

C is incorrect). Pacing has not shown benefit in cardiac

arrest and should not be used (Answer D is incorrect).

Answer: B

Because the rhythm detected is PEA and no longer VF,

the cornerstone of therapy changes from giving defibrilla-

tion (Answer A is incorrect) to giving high-quality chest

compressions and addressing the treatable causes of car-

diac arrest (H’s and T’s) (Answer B is correct). Lidocaine

is reserved for refractory VF/pVT) (defined as defibrilla-

tor refractory) when amiodarone is unavailable (Answer

C is incorrect). Atropine was previously recommended

for PEA/asystole, but in the 2010 ACLS guidelines it was

removed because of a lack of data supporting any benefi-

cial outcomes (Answer D is incorrect).

Answer: C

Temperature control is a consideration, according to

the international guidelines for all patients with ROSC

who remain comatose after a cardiac arrest (Answer A

is incorrect). Although most well-designed and executed

studies primarily enrolled patients with VF cardiac

arrest, application is recommended for all patients with

a cardiac arrest independent of rhythm. Although wors-

ening transaminitis and hepatic enzymatic function

slowing is likely to occur during hypothermia, neither of

these principles would be considered a contraindication

for hypothermia (Answer B is incorrect). Furthermore,

renal function with respect to glomerular filtration

worsens, which requires vigilant monitoring of renal

function and close attention to renal dose modifications

and serum concentration monitoring of medications

when applicable (Answer C is correct). An additional

complication of therapeutic hypothermia is an induced

coagulopathy, which leads patients to be at risk of bleed-

ing. Thrombolytics may carry specific indications for

cardiac arrest (e.g., pulmonary embolism or acute coro-

nary syndromes), but they would not be recommended

empirically (Answer D is incorrect).

Answer: B

Temperature control improves neurologic recovery in

patients after a cardiac arrest (Answer B is correct). Most

patients included in randomized clinical trials have VF

as the causative rhythm (Answers A and D are incor-

rect). Because of its impact on neurologic recovery,

guideline recommendations have applied this literature

to cardiac arrests of all rhythms, and many institutions

have adopted this same recommendation. Recent stud-

ies targeting mild hypothermia (36°C vs. 33°C) have

shown no difference regarding outcomes between the

two modalities, and because of this, some question the

utility of hypothermia at all in an era of potentially more

advanced cardiac arrest care (Answer C is incorrect).

Answer: C

By definition, this patient is having a hypertensive emer-

gency because she has an abrupt, severe increase in

BP with target organ damage—in this case, potentially

shock liver and vision changes. (Answer A is incorrect).

The patient’s SCr is not elevated from baseline and is

thus not presently showing target organ damage (Answer