Shock Syndromes II

A normal TEG and elevated aPTT may not rule out

the presence of dabigatran. In addition, it seems the

patient took the last dabigatran dose within the previous

12 hours. Therefore, dabigatran reversal is indicated.

Idarucizumab is FDA approved for dabigatran reversal

and recommended in various guidelines, whereas PCCs

have weak supporting evidence and are recommended

only if idarucizumab is unavailable (Answer C is cor-

rect; Answer A is incorrect).

Answer: B

This patient has an acute GI hemorrhage complicated

by supratherapeutic INR warfarin and hemodynamic

instability necessitating warfarin reversal with 4F-PCC.

Given his weight and degree of INR elevation, the pack-

age insert dose is 50 units/kg not to exceed 5000 units

(Answer B is correct; Answer D is incorrect). Although

fixed, low-dose PCC has been evaluated for warfarin

reversal, this dose is off-label and supported by a lower

quality of evidence. In addition, the 1000-unit dose has

shown lower achievement of a goal INR, necessitating

rescue doses, and a low dose would probably not achieve

adequate laboratory reversal, given his weight and

excessively high INR (Answer A is incorrect). Finally,

although rFVIIa lowers INR, it is no longer recom-

mended for the reversal of vitamin K antagonists, given

the incomplete correction of factors II, IX, and X and

the possibility that the INR does not reflect the patient’s

underlying coagulopathy (Answer C is incorrect).

Answer: D

The patient has evidence of a PE, but she lacks features

of an increased risk of early mortality from it. She does

not have shock or evidence of end-organ hypoperfusion

and thus does not have a massive PE. In addition, she

has no evidence of RV dysfunction (no RV dilation on

chest CT, brain natriuretic peptide less than 90 pg/mL)

or myocardial necrosis (troponin less than 0.1 mg/mL)

and thus does not have a submassive PE. The patient is

best classified as having a low-risk PE. A meta-analysis

suggested that thrombolytics do not decrease mortality

in unselected (and low risk) patients and may increase

bleeding risk (Answer D is correct; Answers A–C are

incorrect).

Answer: D

The patient has a massive or high-risk PE, as evidenced

by signs of hemodynamic complications requiring nor-

epinephrine, likely confounded by poor physiologic

reserve with chronic obstructive pulmonary disease.

The current guidelines recommend systemic throm-

bolysis in patients with a massive PE and an acceptable

risk of bleeding. This patient does not appear to have

any obvious risk of bleeding, including age; therefore,

systemic thrombolytic agents are indicated in addition

to a therapeutic heparin infusion. The most common

options include alteplase as a fixed dose of 100 mg

infused over 2 hours or tenecteplase adjusted according

to patient weight. Because this patient weighs 140 kg,

the recommended tenecteplase dose would be a 50-mg

intravenous push once (Answer A is incorrect); there-

fore, alteplase 100 mg infused over 2 hours is the most

appropriate answer (Answer D is correct). The 2021

CHEST guidelines state that if thrombolytic agents are

indicated, systemic thrombolysis is preferred to cathe-

ter-directed thrombolytic administration (Answer C is

incorrect). Echocardiogram and cardiac enzymes are

not considered necessary to guide therapy in patients

with hypotension/shock and a CTA-confirmed PE

(Answer B is incorrect).

Answer: A

One of the cornerstones of managing severe cutane-

ous injury includes volume resuscitation, preferentially

with crystalloids (Answer A is correct). The usefulness

of immunomodulating therapies such as corticosteroids

and cyclophosphamide is limited by observational and

poorly controlled evidence or case reports; thus, use of

immunomodulating therapies should be reserved for spe-

cialty centers using formal protocols with consideration

for treatment under clinical study or registry (Answers B

and D are incorrect). Wound care is imperative in these

patients; however, adding unnecessary drugs that could

confound response or worsen the injury (eg, antibiotics)

should be avoided (Answer C is incorrect) unless there is

an objectively suspected or confirmed infection.

Use of IVIG for SJS/TEN is controversial. Available

evidence is from case reports/series, observational

cohort studies, or small, single-center randomized trials

(Answer C is incorrect). Because of bias, limited external

validity, and mixed results/observations between publi-

cations, meta-analyses and consensus guidelines do not

broadly endorse the use of IVIG (Answer D is incorrect).

Available data analyses suggest that IVIG decreases the

SCORTEN-related mortality in patients with TEN and a

middle to higher SCORTEN score; there are even fewer