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ABSITE TRAUMA/ CRITICAL CARE EXAM WITH COMPLETE SOLUTIONS
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ABSITE TRAUMA/ CRITICAL CARE EXAM WITHCOMPLETE SOLUTIONS
Prolonged starvation-ANSWER Prolonged starvation causes a number of metabolic
changes to the body. Among many physiologic changes, the body maintains serum
levels of several minerals at the expense of intracellular depletions. Reintroduction of
nutrition to a chronically malnourished patient may result in dangerous electrolyte shifts
by the inflow of glucose and insulin that promotes synthesis of proteins and fats. The
Na-K ATPase pumps become activated, and the anabolic state promotes the
intracellular shift of magnesium and phosphate. Thus, the classic electrolytes
disturbances are refractory hypophosphatemia, hypomagnesemia, and hypokalemia. If
left uncorrected, patients with refeeding syndrome are at an increased risk for cardiac
arrhythmia and death.
paradoxical embolism - ANSWER foramen ovale
Paradoxical embolism refers to a venous thrombosis that causes systemic embolization
through a right to left shunt. For this entity to take place, four elements must be present.
These are as follows: 1) there must be systemic embolism confirmed on imaging studies,
clinical manifestations, or pathology but without an arterial source or within the left
heart; 2) there must be an embolic source in the venous system; 3) a communication
between the right and left circulations that is intracardiac or intrapulmonary must be
present; and 4) there should be a right to left shunt that is promoted by a pressure
gradient sometime in the cardiac cycle. One of the possible intracardiac
communications between the right and left heart is a patent foramen ovale. Some
reports site that up to 66% of patients with arterial embolism and a patent foramen ovale
have deep venous thrombosis (DVT) found on imaging, and two thirds of the DVT's were
clinically silent.
synchronized cardio version - ANSWER Synchronized cardioversion is timed
(synchronized) with the QRS complex. This prevents the delivery of a shock during that
part of the cardiac cycle when it could cause VF. Indications for synchronized
cardioversion include treatment of supraventricular tachycardia, atrial fibrillation, atrial
flutter, atrial tachycardia, and monomorphic VT with pulses. Synchronized
cardioversion is contraindicated in VF because the device may not detect a QRS wave;
hence, no shock is fired.
,heparin mechanism of action - ANTION Forms a complex with antithrombin to neutralize
formed thrombin and factor Xa.
Antithrombin is a serine protease inhibitor that forms complexes with thrombin and
Factor Xa, resulting in the loss of pro-coagulant activity of these enzymes. The degree of
inhibition of these enzymes increases significantly in the presence of heparin. Patients
with a deficiency in antithrombin have a high propensity to develop pathologic
thrombosis despite receiving medications containing heparin.
Alcohol or drug intoxication - ANSWER Alcohol or drug abuse should be considered as
possible etiologies; hypoglycemia should also be high on the list of differential
diagnoses. This patient is unlikely to have suffered a myocardial infarction. Medications
to counteract narcotic or benzodiazepine overdose with reversal agents should be
administered. Since he is maintaining his airway there is no indication to intubate.
Hyperkalemia and surgery would not be initial treatments.
Septic Shock - ANSWER Early goal-directed resuscitation begins with the administration
of crystalloid, targeted to deliver 30 mL/kg in the initial 3 hours. Vasopressor therapy is
initiated for hypotension that is refractory to this crystalloid infusion. The vasopressor
agent of choice is norepinephrine. Steroid therapy is indicated for hypotension that is
refractory to both crystalloid and vasopressor therapy. Sodium bicarbonate is
recommended as an adjunct therapy if pH is less than 7.15.
ARDS long term sequel - ANSWER decreased pulmonary diffusing capacity
Acute lung injury and the adult respiratory distress syndrome (ARDS) affect at least
150,000 patients in the United States each year. Recent investigation, in limited
numbers of patients, has shown that approximately two thirds have some degree of
residual physiologic pulmonary impairment when examined more than 12 months after
recovery. Exertional dyspnea is the symptom most commonly reported. It is generally
mild, but may cause interference with daily activities, like the inability to climb steps in
some patients. A reduced single-breath carbon monoxide diffusing capacity is the most
common pulmonary defect after ARDS. The basis for this persistent impairment is not
known, but is likely related to injury at the capillary level with a thickened
alveolar-capillary interface (replacement of type I lining cells by cuboidal cells) and
pulmonary fibrosis. Spirometric abnormalities may also be present, but tend to be mild.
For example, FVC was 92% of predicted at one year among a group of 12 survivors.
Total lung capacity and functional residual capacity are often reduced during the first
few months after ARDS, but increase and stabilize 6 to 12 months later. In most
survivors of ARDS, total lung capacity returns to predicted levels within the first year.
VAP - ANSWER MSSA, Strep sp. and Haemophilus influenzae
,The most common early offending organisms are sensitive Gram positives and H.
influenzae.
A 71-year-old gentleman with colon cancer is admitted to the intensive care unit
following left hemicolectomy surgery. His vital signs are as follows: Blood pressure
72/38 mm Hg, pulse rate 114/min, respiratory rate 23/min, oxygen saturation 94% while
receiving 2 L of oxygen via nasal cannulae. A pulmonary artery catheter shows the
following: central venous pressure 8 cm H 2O, pulmonary artery pressure 22/8 mm Hg,
pulmonary artery wedge pressure 6 mm Hg, cardiac output 3.4 L/min. The next step in
management should include the intravenous administration of - ANSWER Swan-Ganz
measurements of intra-arterial and intra-cardiac pressures can differentiate between
etiologies of shock and hypotension. This patient has a low blood pressure with high
compensatory heart rate. His pulmonary status appears normal. The pulmonary artery
pressure is normal, indicating a normally functioning right ventricle. PAWP is
low-normal, indicating an under-filled left atrium and by extension left ventricle. CO is
low. Because CO is a product of stroke volume x heart rate (SV x HR), the tachycardia
suggests a low stroke volume. This patient is volume-depleted and should receive a fluid
bolus. Dobutamine is not indicated since the patient is already tachycardic; further
increases in heart rate may depress diastolic blood return to the myocardium. The
phenylephrine and dopamine (in high doses) are α-antagonists and confer
vasoconstriction; neither address the underlying volume depletion. The β-blocker
metoprolol would decrease the compensatory high heart rate and further depress blood
pressure. The CVP is normal, presumably indicating adequate right atrial volume;
however, there is mounting evidence that the CVP is not an accurate predictor of
preload.
A 25-year-old male gymnast falls on the balance beam during practice, and is brought to
the emergency room for severe perineal pain. Examination reveals a perineal hematoma
and blood at the urethral meatus. Secondary survey reveals no other significant injuries.
He is hemodynamically normal. What is the most appropriate next step in management?
- ANSWER Retrograde urethrogram
This patient's history and examination are consistent with blunt perineal/urinary tract
injury. A high suspicion for urethral injury should be entertained. Performance of a
retrograde urethrogram is the initial step in management. Obtain a baseline abdominal
radiograph (KUB). Fill a 60 mL syringe with 10 percent water-soluble contrast (diluted in
sterile saline) and attach a Christmas tree adaptor. Insert the adaptor snugly into the
urethral meatus ensuring a tight fit because leaking contrast will result in a spurious
study. Alternatively, insert a Foley (ie, bladder or urinary) catheter several centimeters
into the urethra and inflate the balloon enough to prevent its falling out but not so tight
as to block off the fossa navicularis. Attach a catheter-tip syringe containing 50 to 60 mL
of contrast (0.6 mL/kg in children) with the addition of a small amount of epinephrine
, (1:100,000). Inject slowly, taking a KUB during the infusion of the final 10 mL. Lack of
urethral extravasation with contrast entering the bladder defines a normal study. A
partial disruption is demonstrated by urethral extravasation accompanied by contrast
entering the bladder. A complete disruption results in urethral extravasation with no
contrast entering the bladder. CT is not helpful for imaging the urethra, and is otherwise
unnecessary in this patient. Cystoscopy and/or catheterization (suprapubic or urethral)
are reasonable, but only after initial urethrogram.
Which of the following primary muscle(s) is(are) responsible for elevation of the rib cage
during inspiration? - ANSWER The external intercostals are the primary muscles
responsible for rib cage elevation during inspiration.
The anterior serrati elevate several of the ribs, the scaleni elevate the first two ribs, the
diaphragm pulls the lower lung surfaces inferiorly, and the sternocleidomastoid
elevates the sternum.
The patient is an 85-yr-old female admitted with cardiogenic shock and a history of
emphysema, who cannot tolerate the Trendelenburg position. Under ultrasound
guidance, a central venous catheter is placed into the right internal jugular vein. During
the dressing, the patient begins to complain of progressive dyspnea. The patient
becomes obtunded, hypotensive, and tachycardic. Chest auscultation reveals bilateral
breath sounds. Apart from securing the airway, which of the following is the most
appropriate immediate intervention? -ANSWER Place the patient in the Trendelenburg
position with left lateral decubitus position and aspirate from the catheter.
Explanation: The patient has developed a venous air embolism, a less frequent
complication associated with central venous catheters. A volume of as little as 20 mL of
aspirated air can cause a venous air embolism. Again, air may enter the venous system
during the placement if the ports on the catheter are left open or negative pressure is
not applied on the needle during insertion. The risk is reduced if the patient is in the
Trendelenburg position and the catheter is placed under expiration (positive
intra-thoracic pressure). Air may also enter the venous system during catheter removal
if direct pressure is not applied over the site.
Management consists of placing the patient in left lateral decubitus position and
Trendelenburg to prevent air from entering the right ventricle. Aspiration of the air may
be attempted. The patient should also be placed on a Fio2 of 1.0 to attempt reabsorption
of the air.
Compared to IMV, APRV: -ANSWER The goal of mechanical ventilatory support for
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