210.An 18-year-old college student with no past medical history presents
to the ED with a diffuse rash. She also describes having a headache, fever,
and arthralgias for 3 days. On examination, her temperature is 101.2°F, B P
is 120/63 mm Hg, HR is 110 beats per minute, RR is 24 breaths per
minute, and oxygen saturation is 98% on room air. The patient is alert and
oriented to person, place, and time. She has nuchal rigidity and photopho-
bia. Her gums are oozing blood. Her abdomen is soft and nontender and
her skin has a diffuse, petechial rash. You are concerned about meningo-
coccemia and immediately start ceftriaxone and vancomycin. Her labora-
tory results reveal a white blood cell (WBC) count of 13,400/μL,
hematocrit 36%, platelets 80/μL, PTT 60 seconds, international normal-
ized ratio (INR) 1.9, and fibrinogen 250 g/L. Which of the following is the
most appropriate next step in management?
a. IV heparin
b. Transfuse cryoprecipitate
c. Transfuse packed red blood cells (RBC)
d. Transfuse platelets
e. Transfuse fresh frozen plasma (FFP)
211.An 82-year-old man with a history of COPD and hypertension pre-
sents with shortness of breath and fever. His medications include albuterol,
ipratropium, prednisone, hydrochlorothiazide, and atenolol. His tempera-
ture is 102.1°F, BP is 70/40 mm Hg, HR is 110 beats per minute, RR is
24 breaths per minute, and oxygen saturation is 91% on room air. The
patient is uncomfortable and mumbling incoherently. On chest examina-
tion, you appreciate rales on the left side of his chest. His heart is tachy-
cardic, but regular with no murmurs, rubs, or gallops. His abdomen is soft
and nontender. You believe this patient is in septic shock from pneumonia
and start IV fluids, broad-spectrum antibiotics, and a dopamine drip. His
BP remains at 75/50 mm Hg. Which of the following is the most appropri-
ate next step in management?
a. D5 normal saline IV bolus
b. Phenylephrine IV drip
c. Fludrocortisone IV
d. Hydrocortisone IV
e. Epinephrine IV drip
Shock and Resuscitation 217