IV fluids, antibiotics, and dopamine is appropriate. Continued hypoten-
sion in a patient on maintenance steroid therapy should make you think of
adrenal crisis. Exogenous glucocorticoids suppress hypothalamic release of
corticotropin-releasing hormone (CRH) and subsequently anterior pitu-
itary release of adrenocorticotropic hormone (ACTH). The adrenals subse-
quently atrophy from lack of stimulation. The patient is now faced with an
acute stress from pneumonia and sepsis. His adrenals have atrophied and
are unable to respond with increased cortisol secretion. Laboratory clues to
adrenal crisis include hyponatremia and hyperkalemia caused by a lack of
aldosterone. The treatment of adrenal crisis in the face of septic shock is
hydrocortisone.
Mineralocorticoids, such as fludrocortisone (c), are not needed. Addi-
tional fluids (a)and pressors (b and e)are appropriate critical-care
managementfor sepsis and should be administered after glucocorticoids.
212.The answer is c.(Tintinalli, pp 1036-1037, 1105-1108.)Toxic inges-
tions must always be considered, especially in suicidal patients. The patient
regularly takes atenolol for hypertension and may have overdosed on this
occasion.β-Blocker toxicityclassically causes bradycardia and hypoten-
sion. Antidotes for β-blocker toxicity, such as glucagon,should be given to
this patient immediately. Glucagon is thought to work through a separate
receptor that is not blocked by β-adrenergic antagonists, ultimately enhanc-
ing inotropy and chronotropy. Other medications that may be useful are
phosphodiesterase inhibitors, which block cAMP breakdown and maintain
intracellular calcium levels. High-dose insulin is a promising experimental
treatment for β-blocker toxicity. Ultimately, the patient may require the
other treatment options, but glucagon should be the first-line therapy.
You should administer an IV bolus of fluids (a), you may attempt to
administer atropine (b), and place external cardiac pacers on the patient (e).
However, because this is a β-blocker overdose, the administration of
glucagon should treat the patient. (d)Epinephrine should be administered
if the patient loses his pulse.
213.The answer is d.(Tintinalli, pp 1605-1607.)Patients with penetrating
trauma to the chest with possible cardiac injury and signs of hemodynamic
instability need immediate operative thoracotomy.This patient has signs
of cardiac tamponade, a collection of blood surrounding the heart and inter-
fering with the heart’s ability to contract. He has Beck triad of hypotension,
distended neck veins, and muffled heart sounds. His CXR also shows an
enlarged heart. An echocardiogram would be helpful in confirming the
232 Emergency Medicine