Regarding the use of vasoactive agents in the ED, which ONE of the following statements is TRUE?
Answer: B: Metaraminol is a potent and selective α-agonist and therefore does not exhibit any positive inotropic effects. This makes it a useful agent for managing hypotension in patients with severe aortic stenosis or hypertrophic cardiomyopathy.
Although administration of dobutamine via the central route is preferred, it can safely be infused via the peripheral route. Infusion of adrenaline and noradrenaline should be restricted to the central route. Due to the absence of β2 effects, noradrenaline causes no or minimal vasodilation in skeletal muscle vasculature. Therefore, it causes an increase in systolic as well as diastolic BP. Even though noradrenaline is currently the recommended first-line vasopressor agent in septic shock, this has mainly been based on pathophysiological principles and to date there is no evidence that adrenaline is any worse than other vasoactive agents in terms of mortality outcome.
References:
Regarding the use of hypertonic saline in traumatic brain injury (TBI), which ONE of the following statements is TRUE?
Answer: B: Hypertonic saline has been shown to reliably decrease intracranial pressure (ICP) in patients with traumatic brain injury (TBI) (LOE II) and it is at least as effective as mannitol. However, no studies so far have demonstrated improved cerebral blood flow; neither is there good evidence showing an outcome benefit. Despite the potential benefits in reducing ICP in patients with TBI, there is currently no evidence to recommend hypertonic saline over isotonic saline for fluid resuscitation and restoration of the intravascular volume.
Reference:
Which ONE of the following subset of trauma patients will MOST likely benefit from ‘hypotensive resuscitation’?
Answer: A: Fluid resuscitation in trauma remains a controversial topic. However, hypotensive resuscitation, also known as ‘permissive hypotension’ or ‘small volume resuscitation’, is advocated in patients with a strong potential for ongoing internal haemorrhage (uncontrolled bleeding) until rapid surgical control of bleeding can be achieved. Most studies supporting deliberate hypotension were performed on patients with penetrating thoracoabdominal trauma, and the most significant results were observed in cases in which distinct vascular injuries were the main source of haemorrhage. This approach still remains controversial in the setting of multi-site blunt trauma and severe head injury. Traditional fluid resuscitation is recommended for patients with controllable haemorrhage, isolated extremity injuries and isolated traumatic brain injury.
Regarding resuscitative thoracotomy in penetrating trauma due to a precordial stab wound, which ONE of the following statements is TRUE?
Answer: A: Resuscitative thoracotomy is a dramatic intervention performed outside of the operating room and usually in the absence of trained cardiothoracic surgeons. The role of resuscitative thoracotomy is more established in penetrating trauma, especially in cardiac stab wounds, and best results are obtained for pericardial tamponade. Better survival has been reported with the penetrating mechanism, with a survival rate of >40% reported in traumatic arrest, specifically precordial stab wounds. Survival was dependent on thoracotomy performed within 10 minutes of arrest and the presence of an organized cardiac activity. Unresponsive hypotension with a systolic blood pressure <70 and a FAST positive for pericardial tamponade is a consensus-based indication for immediate resuscitative thoracotomy. The usual trauma resuscitation principles are valid in penetrating injuries to the thorax. A tension pneumothorax can present in a similar way (distended neck veins, hypotension and tachycardia) and should be excluded prior to embarking on resuscitative thoracotomy as a less dramatic intervention such as decompression needle thoracostomy or open thoracostomy can be performed. The role of resuscitative thoracotomy in blunt trauma is more controversial, with a relatively low survival rate of <3%.
Regarding transfusion-related acute lung injury (TRALI), which ONE of the following is TRUE?
Answer: B TRALI presents abruptly, usually within 6 hours of transfusion of plasma containing blood products (FFP, packed cells, platelets, cryoprecipitate). It results from the transfusion of white blood cell antibodies (leukoagglutinins) that react with the recipient’s leucocytes. Clinically, TRALI is indistinguishable from ARDS. The patient has acute respiratory distress, diffuse bilateral alveolar and interstitial infiltrates on chest X-ray, and varying degree of hypoxaemia. The overall prognosis is better than what would be expected with many other causes of ALI.
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