Shock and Resuscitation
Answers
190.The answer is c. (Tintinalli, pp 242-247.) This patient is in
cardiogenic shockfrom decreased cardiac outputproducing inadequate
tissue perfusion. Support for this diagnosis includes an older patient with
a history of coronary artery disease, and new mental status changes cou-
pled with signs of volume overload. Common causes of cardiogenic shock
include acute MI, pulmonary embolism, COPD exacerbation, and pneu-
monia. This patient should be stabilized with IV pressors since there is
already pulmonary congestion evident on examination. A rapid workup
including ECG, chest x-ray (CXR), laboratory tests, echocardiogram, and
hemodynamic monitoring should help confirm the etiology and direct spe-
cific treatment of the underlying cause.
Hypovolemic shock (a)occurs when there is inadequate volume in the
circulatory system, resulting in poor oxygen delivery to the tissues. Neuro-
genic shock (b)occurs after an acute spinal cord injury, which disrupts
sympathetic innervation resulting in hypotension and bradycardia. Ana-
phylactic shock (d)is a severe systemic hypersensitivity reaction resulting
in hypotension and airway compromise. Septic shock (e)is a clinical syn-
drome of hypoperfusion and multiorgan dysfunction caused by infection.
191.The answer is d. (Tintinalli, pp 185-187.) This patient has
supraventricular tachycardia (SVT),a narrow complex, regular tachy-
cardia. It is caused by a reentry or an ectopic pacemaker in areas of the
heart above the bundle of His, usually the atria. Regular P waves will be
present, but may be difficult to discern owing to the very fast rate. The
patient in this case has normal vital signs and examination, and is therefore
stable. First-line treatment for a patient with stable SVT is vagal maneu-
verstoslow conduction and prolong the refractory period in the AV
node.The Valsalva maneuver can be accomplished by asking the patient to
bear down as if they are having a bowel movement and hold the strain for
at least 10 seconds. Other vagal maneuvers include carotid sinus massage
(after auscultating for carotid bruits) and facial immersion in cold water.
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