while the diagnostic workup continues. Blood is indicated after 2 to 3 L of
crystalloid infusion and only minimal improvement in vital signs or when
the patient has obviously suffered significant blood loss.
209.The answer is e.(Rosen, pp 73-74.)The rhythm is asystole.This
rhythm represents complete cessation of myocardial electrical activity.
Although asystole may occur early in cardiac arrest because of progressive
bradycardia, it generally represents the end-stage rhythm after prolonged
cardiac arrest secondary to VF or PEA. Because the potential exists for an
organized rhythm or VF to appear as asystole in a single lead, asystole
should always be confirmed in at least two limb leads.It may be difficult
to distinguish between extremely fine VF and asystole. Treatment includes
CPR, intubation, IV access, and the administration of epinephrine or vaso-
pressin and atropine.
(a)Synchronized cardioversion is energy delivered to match the QRS
complex. This reduces the chance that a shock will induce VF. Synchro-
nization is used to treat tachydysrhythmias (eg, rapid atrial fibrillation) in
hemodynamically unstable patients. It should not be used in asystole.
(b and c)Immediate defibrillation is used in VF and VT. Although some
clinicians shock asystole in the event it is actually fine VF, this has not been
shown to improve patient outcome. Epinephrine and atropine should be
administered first. (d)Amiodarone is an antidysrhythmic that is only effec-
tive if there is a rhythm (eg, VT); asystole is the lack of a rhythm.
210.The answer is e.(Tintinalli, pp 1327-1329, 1518.)This patient has
signs of disseminated intravascular coagulation (DIC) secondary to
meningococcemia. She should be treated with FFPfor elevated coagula-
tion times (INR and PTT) with signs of active bleeding (oozing gums). FFP
will provide lost clotting factors and help to control the bleeding.
Studies involving heparin therapy (a) are inconclusive regarding
increased survivability in DIC and therefore can be held until further dis-
cussion with the appropriate consultants. Cryoprecipitate (b)contains
concentrated Factor VIII and fibrinogen. It is helpful in DIC when the fib-
rinogen is less than 150 mg/dL. Platelets (d)should be transfused when the
count is below 20,000/μL or below 50,000/μL in patients with active
bleeding. RBCs (c)can be transfused if the anemia is causing symptoms.
211.The answer is d.(Tintinalli, pp 1315-1318.)This patient is in septic
shockfrom pneumonia and also has adrenal crisis.Initial treatment with
Shock and Resuscitation Answers 231