is confirmed, a Sager or Hare traction splint should be applied and ortho-
pedics consulted. Other areas of life-threatening hemorrhage in trauma
include the chest, abdomen, retroperitoneum, and pelvis. It is also impor-
tant to keep in mind that significant blood loss could have occurred at the
scene despite no obvious active bleeding in the ED.
Neurogenic shock (b)occurs after an acute spinal cord injury, which
disrupts sympathetic innervation resulting in hypotension and bradycardia.
Cardiogenic shock (c)is caused by decreased cardiac output producing
inadequate tissue perfusion. Anaphylactic shock (d)is a severe systemic
hypersensitivity reaction resulting in hypotension and airway compromise.
Septic shock (e)is a clinical syndrome of hypoperfusion and multiorgan
dysfunction caused by infection.
196.The answer is d.(Chauhan, 2006.)Low-energy cardioversion is very
successful in converting atrial flutter to sinus rhythm. Remember, car-
dioversion is different than defibrillation. Cardioversion is performed on
patients with organized cardiac electrical activity with pulses, whereas
defibrillation is performed on patients without pulses (VF and VF without
a pulse). Patients with heart beats who receive electrical energy during their
heart’s relative refractory period are at risk for VF. Therefore, cardioversion
is a timed shock designed to avoid delivering a shock during the heart’s rel-
ative refractory period. By activating synchronization mode,the machine
will identify the patient’s R waves and not deliver electrical energy during
these times. The key step when cardioverting is to activate the synchro-
nization mode and confirm the presence of sync markers on the R waves
prior to delivering electrical energy.
197.The answer is b.(American Heart Association Guidelines, 2005.)This
patient has cardiac electrical activity (sinus bradycardia), but no detectable
pulses. He is therefore in a state of pulseless electrical activity(PEA)and
management should be directed by the AHA PEA algorithm. Patients in
PEA should be treated with CPR, epinephrine every 3 to 5 minutes, and
atropine every 3 to 5 minutes (if PEA rate is less than 60 per minute), but
a search for an underlying etiology with targeted interventions should still
be performed.
Common etiologies for PEA are shown in the table on the next page
along with their specific treatments. Many find the H’s and T’sin the table
an easy way to remember the differential. Each etiology should be consid-
ered for every patient with PEA and causes that are more likely given a
224 Emergency Medicine