Shock Syndromes II

tachycardia

and

elevated

serum

creatinine.

extremities.

A 44-year-old man (weight 82 kg) presents to the

ED after a motor vehicle collision at highway

speeds. On primary survey, his King airway device

is replaced for an endotracheal tube; his respiratory

rate is 37 breaths/minute, systolic blood pressure

(SBP) is 77 mm Hg, heart rate is 146 beats/minute,

and Glasgow Coma Scale score is 3. In addition, he

is noted to have a positive seatbelt sign. The Focused

Assessment with Sonography in Trauma (FAST)

examination is positive. He is taken to the operat-

ing room for an emergency exploratory laparotomy.

Which best represents the most appropriate initial

transfusion, resuscitation, and hemostasis strategy

to achieve hemodynamic stability?

followed by a 2-unit transfusion of erythrocytes.

Ringer solution and a tranexamic acid 1-g

bolus, followed by 1 g infused over 8 hours.

thromboplastin time (aPTT), fibrinogen, and

complete blood cell count to guide initial

resuscitation.

and plasma in a 1:1 ratio plus a tranexamic acid

1-g bolus and 1 g infused over 8 hours.

H.S. is a 76-year-old man (weight 142 kg) with a

history of several pulmonary embolisms (PEs) and

associated chronic thromboembolic pulmonary

hypertension (CTEPH) on warfarin who is admit-

ted to the ED with weakness and hematemesis.

Pertinent vital signs on admission are as follows:

blood pressure 82/46 mm Hg, heart rate 121

beats/minute with a rhythm of sinus tachycardia,

and respiratory rate 22 breaths/minute. Frank red

blood is noted on nasogastric lavage. On physi-

cal examination, the patient is confused, with

clammy extremities. Pertinent laboratory values are

as follows: Hgb 5.2 g/dL, BUN 52 mg/dL, SCr 2

mg/dL, INR 9.2, and platelet count (Plt) 120,000/mm3.

Which is most effective to immediately reverse his coag-

ulopathy secondary to warfarin?

PCC) 50 units/kg intravenously infused over 30

minutes.

A 66-year-old man with a medical history of non–

small cell lung cancer presents to the ED with

new-onset shortness of breath. A chest computed

tomography (CT) scan reveals a PE at the bifurca-

tion of the right and left pulmonary arteries. The

patient is initiated on parenteral anticoagulation and

transferred to the medical intensive care unit (ICU).

On ICU admission, he develops pulseless electrical

activity (PEA). He is intubated and mechanically

ventilated, with recovery of spontaneous circulation

after one round of chest compressions and epineph-

rine 1 mg. Which is the next best step to evaluate

and/or treat this patient’s PE?

hours.

Questions 6–8 pertain to the following case.

R.M is a 78-year-old man with a history of alcoholic

cirrhosis and portal hypertension who is in an urban,

academic ICU after treatment of a variceal hemorrhage

(now stable) and respiratory failure. Five days after

admission, he develops hypoxemia (partial pressure

oxygen saturation [Pao2] 78%), requiring an increased

fraction of inspired oxygen (Fio2) on the ventilator. A

chest computed tomography angiography (CTA) reveals

several filling defects at the bifurcation of the main pul-

monary artery, suggesting a “saddle” PE. His heart rate

is 142 beats/minute with a rhythm of sinus tachycardia.

His blood pressure is 97/62 mm Hg and current weight

is 87 kg. R.M. has a TTE that reveals right ventricular

(RV) hypokinesis and tricuspid regurgitation. His car-

diac troponin I (0.6 ng/mL) and troponin T (0.2 ng/mL)

are positive.