NBME 10 and 11. Heart trauma and shock Flashcards
NBME 10 131Q.
67 y/o + Hx of MI + now 2-day history of progressive fatigue, confusion, shortness of breath with exertion, and difficulty breathing when she lies flat. At night, she has had the sudden need to run to an open window for air. The daughter says that she does not know if her mother has taken her medications during the past 2 days. On arrival, the patient appears ill and in mild respiratory distress; she is ashen. Temp. 36.4°C, pulse 102/min and regular, RR 24/min, BP 82/46 SpO2 89%. Examination shows jugular venous distention. Crackles are heard throughout the lower lung fields. On cardiac examination, an S3 gallop is heard. There is 2+ pitting edema at the ankles. Intravenous administration of which of the following is the most appropriate next step in pharmacotherapy?
Dopamine
NBME 10 131Q. Cardiogenic shock with Hx of MI.
Appropriate pharmacotherapy for cardiogenic shock should provide positive inotropic support. This can be accomplished with? 3 drugs
dopamine, dobutamine, norepinephrine, or a combination of these medications.
NBME 10 131Q. Cardiogenic shock with Hx of MI.
While norepinephrine as monotherapy or in conjunction with dobutamine is more commonly used for the treatment of cardiogenic shock in current practice, dopamine, when given at the correct dose, is also an appropriate choice
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NBME 10 131Q. Cardiogenic shock with Hx of MI.
Dopamine targets different receptors at different concentrations. At low dose, it acts on ??? cause??
acts on D1 receptors and actually causes vasodilation and may lead to hypotension.
NBME 10 131Q. Cardiogenic shock with Hx of MI.
Dopamine targets different receptors at different concentrations. At mid-range dose, it acts on ??? cause??
At midrange doses of 5 to 10 mcg/kg/min, it stimulates β1 receptors and augments cardiac output, thereby increasing the mean arterial pressure.
NBME 10 131Q. Cardiogenic shock with Hx of MI.
Dopamine targets different receptors at different concentrations. At higher dose, it acts on ??? cause??
At higher doses, dopamine acts on α1 receptors and further increases the systemic vascular resistance, but it also has a tendency to cause dangerous arrhythmias, so doses in this range are not frequently used.
NBME 10 131Q. Cardiogenic shock with Hx of MI.
Mortality outcomes are comparable across chosen vasopressors; however, morbidity and complications were shown in the SOAP II trial to be worse in patients treated with dopamine.
bet ats vis tiek buvo dobutamine sitam klausime
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NBME 11 16Q. A 51-year-old man, hospitalized for management of a proximal jejunal enterocutaneous fistula, has a 2-day history of fever and malaise. Four weeks ago, he underwent laparotomy for a gunshot wound to the
abdomen; the fistula was noted 1 week after the operation. Since undergoing the laparotomy, he has received total parenteral nutrition through a left subclavian central catheter. During the past 2 weeks, he
has participated in physical therapy; until today, he was able to ambulate 300 ft and walk up two flights of stairs without shortness of breath. He has no other history of serious illness. His medications are
somatostatin and morphine. His temperature is 38.4°C (101.1°F), pulse is 105/min, respirations are 20/min, and blood pressure is 110/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows the fistula opening with draining enteric contents. An ostomy pouching system is placed, and the surrounding skin is well protected. Fistula output is 400 mL daily. Three days ago, his leukocyte count was 8000/mm ; today, it is 14,000/mm . Serum studies today show an albumin concentration of 2.7 g/dL and prealbumin concentration of 19 mg/dL (N=19.5–35.8). Which of the following is the most appropriate next step in management?
Blood cultures from the catheter site
Evaluation includes blood cultures obtained from the central line and an alternative site. Most patients should be started on broad-spectrum intravenous antibiotics and should have their central line removed.
NBME 11 16Q.
Blood cultures from the catheter site is the most appropriate next step in management of this patient on total parenteral nutrition (TPN) through a central line and new onset fever and leukocytosis. The presence of a long-term intravenous catheter substantially increases the risk for bacteremia leading to sepsis, which is known as a catheter-associated blood stream infection (CLABSI). Additionally, fungemia should also be suspected in patients who have recently undergone abdominal surgeries and are on TPN, but this is less common than bacteremia. All patients who are being evaluated for sepsis should have anaerobic and aerobic blood cultures drawn from two different sites. In patients with a central venous catheter, at least one of these sets should be obtained from the central line. Removal of the central venous catheter is recommended in almost all circumstances, although there are some rare instances in which patients may receive treatment for bloodstream infections while their central line remains in place. Following blood cultures, empiric antibiotics should be started.
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NBME 11 16Q. catheter-infection.
Exploratory laparotomy and resection of the fistula (Choice D) would only be indicated if there was evidence of peritonitis on examination, but this patient’s abdominal examination has not changed significantly.
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NBME 11 16Q. catheter-infection.
CT scan of the abdomen (Choice C) might be considered if this patient were to develop worsening abdominal pain and were suspected of having a new intra-abdominal infection, but his abdominal examination is benign.
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NBME 11 16Q. catheter-infection.
Intravenous antifungal therapy (Choice E) should be considered if this patient has persistent fevers despite the initiation of broad-spectrum antibiotics, or if fungal elements are identified in his blood cultures. Patients on TPN are at a higher risk for invasive fungal infections than the general population.
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NBME 11 18Q. A 42-year-old man is brought to the emergency department by ambulance 20 minutes after sustaining a
stab wound to his right anterior chest. On arrival, the patient is uncooperative, refusing to lie flat on the gurney. Medical history is unremarkable, and he takes no medications. He says he drank six 12-oz beers and used cocaine today. Vital signs are pulse 130/min, RR 28/min, BP 66/40 mm Hg. SpO2 99%. The patient appears anxious. Physical
examination discloses a single stab wound in the medial right anterior chest, 3 cm below the right nipple. The trachea is midline. Breath sounds are present bilaterally. Cardiac examination discloses distant but normal S and S . Abdominal examination discloses no abnormalities. Which of the following is the most 12
appropriate next step in management?
Focused assessment with sonography for trauma (FAST).
Concern is pericardial tamponade. Further assessment using bedside ultrasonography should be the next step in diagnosis. Emergent pericardiocentesis or pericardial window must be done to resolve cardiac tamponade.
This patient should also receive large bore intravenous access and immediate resuscitation with crystalloid followed by blood products prior to performing any diagnostic test because of his degree of hemodynamic instability.
NBME 11 18Q. Cardiac tamponade after knife injury. kiti ats.
Chest x-ray (Choice A) is an important part of the trauma survey and can evaluate for rib fractures, pneumothorax, hemothorax, or widened mediastinum in great vessel injury. Similarly, CT scan of the chest (Choice B) is able to evaluate lung parenchyma and is more sensitive for rib fractures. A chest x-ray would not be able to identify pericardial effusion or acute cardiac tamponade but may show an enlarged or misshapen cardiac silhouette in such cases. While a CT scan of the chest can identify a pericardial effusion, this patient is hemodynamically unstable and unable to lay flat for a CT scan at this time; ultrasonography is a rapid diagnostic test that can be done at the bedside.
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NBME 11 60Q. 16 y.o + motor vehicle collision. moderate chest pain. His pulse is 100/min, respirations are 20/min, and blood pressure is 130/80 mm Hg. Examination shows erythema over the chest in the area where his seat belt had been fastened. biski padideje tropai (I and T), padideje CK. ecg - sinus tachy, nonspecific T-wave inversion
in leads V3 through V6. NEXT STEP?
Serial ECG monitoring
Patients may present with chest pain, increased concentrations of troponins, and a wide array of potential ECG changes. Patients with ECG changes should be admitted for observation and serial ECG monitoring.
NBME 11 60Q. Blunt trauma to the chest and now has chest pain, mildly increased troponin concentration, and ECG showing T-wave inversions most likely has a myocardial contusion.
ECG changes are highly diverse, and patients may develop anything from new bundle branch blocks to cardiac conduction delays, supraventricular tachycardia, or nonspecific ST-segment changes. When any abnormality is identified on ECG, the patient should be admitted to the hospital for serial monitoring with ECGs to assess for progression to malignant arrhythmia, heart failure, or rupture.
NBME 11 60Q. kiti ats. hyperoxygenation when used?
employed to treat pneumothorax as it is believed to help resolve the pneumothorax more expediently.
NBME 11 60Q. kiti ats. β-adrenergic blocking agent when?
Would be appropriate if this patient was found to have evidence of an aortic dissection or within the first 24 hours of a hemodynamically stable acute coronary syndrome. His presentation is more consistent with myocardial contusion.
NBME 11 60Q. kiti ats. Intravenous administration of 0.45% saline?
This patient has no indication for intravenous fluids because his blood pressure is normal and there is no evidence of hypovolemia
