A 55-year-old man with a history of chronic obstructive pulmonary disease (COPD) (no home O2 , FEV1 67% predicted) presents to the emergency department with shortness of breath and lightheadedness that started suddenly 4 hours prior. He underwent a right knee replacement 6 months prior but otherwise has not been in the hospital recently and has felt well. His only current medication is an albuterol inhaler. He has no other past medical history.
His vitals are:
On examination, he is anxious, with clear lung fields and cold extremities and mottled skin. A chest radiograph does not reveal any acute process, and a chest computed tomography (CT) with pulmonary angiography demonstrates bilateral segmental pulmonary emboli. He is given 2 L of intravenous (IV) lactated ringers (LR) solution and is complaining of dizziness and noted to be confused. His repeat vitals are HR 105 beats/min, BP 70/40 mm Hg, respiratory rate 20/min, and SpO2 88% on room air. In addition to supportive care and appropriate triage, what is the most appropriate next step?
Correct Answer: D
This patient presents with obstructive shock from pulmonary embolism (PE). PE may be categorized as “massive” based on the presence of sustained hypotension (systolic BP <90 mm Hg for at least 15 minutes or requiring inotropic support, not because of a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or LV dysfunction), pulselessness, or persistent profound bradycardia (HR <40 beats/min with signs or symptoms of shock). In the setting of massive PE, clinical guidelines recommend administration of systemic thrombolytic therapy based on evidence demonstrating improved mortality. Thrombolysis may be contraindicated if patients have a high-bleeding risk, including having undergone major surgery within 3 weeks or presentation, however our patient’s distant surgery and lack of other risk factors make him a good candidate for full-dose systemic thrombolysis (answer D is correct). Systemic thrombolysis at half dose has been examined in patients at increased bleeding risk and in the treatment of submassive PE. Data are not conclusive about the benefit of this strategy over others in submassive PE, and full-dose systemic thrombolysis would be most appropriate in massive PE.
IV heparin infusion will ultimately be necessary for this patient, but alone is insufficient; heparin stabilizes the clot while the endogenous fibrinolytic system reduces the clot size over the course of days to months (answer C is incorrect). When administered in PE, a bolus should be performed as it allows a therapeutic level of anticoagulation to be achieved at a faster rate (answer B is incorrect).
Administration of additional IV crystalloid targets suspected intravascular volume depletion. However, the patient has worsened despite receiving 1L of IV fluids. In addition to the fact that fluids do not correct the underlying disease, in acute right heart failure, aggressive volume repletion can worsen interventricular dependence and decrease LV cardiac output.
A 65-year-old woman with acute myeloid leukemia is undergoing induction chemotherapy as an inpatient. On hospital day 4, she is noted to be hypotensive, febrile, and rigoring. Lactic acid is measured at 5 mmol/L. She is transferred to the intensive care unit (ICU) and her laboratory results from that morning are reviewed. They are notable for an absolute neutrophil count of 120/µL and a creatinine that is elevated to 3 mg/dL from a baseline of 1.2 mg/dL.
Which of the following interventions have been demonstrated to improve mortality for this patient population?
Correct Answer: B
This patient is presenting with neutropenic septic shock, a form of distributive shock incited by an infectious etiology. Patients with neutropenic septic shock are at high risk for infection with both resistant gram-negative and gram-positive organisms. Patients in septic shock experience mortality benefit from early administration of appropriate antibiotic therapy (answer B is correct). In the initial 6 hours following the onset of hypotension, every 1-hour delay in antibiotic therapy may be associated with an increase in mortality of greater than 7% in a broad septic shock population.
Timing of renal replacement therapy in septic shock has been examined in several large randomized trials. Routine early renal replacement therapy does not appear to improve outcomes and leads to an increased rate of renal replacement therapy when compared with the later initiation of renal replacement therapy guided by clinical indications (answer A is incorrect). Procalcitonin has been investigated to guide de-escalation of antibiotics in the emergency department and inpatient setting, however does not impact mortality in septic shock (answer C is incorrect). Similarly systemic antifungals are not recommended as first line in septic shock, and their early administration has not been shown to improve mortality (answer D is incorrect). Finally, multiple large multinational randomized trials failed to demonstrate that fluid administration guided by specific biomarkers or resuscitation protocols improved mortality when compared with usual care (answer E is incorrect).
A 56-year-old man with diffuse large B-cell lymphoma develops shortness of breath, wheezing, and hypotension while in the chemotherapy infusion center. His second infusion of rituximab treatment was initiated several minutes before the start of his symptoms. He was otherwise asymptomatic at the time of arrival to the infusion appointment.
His vitals signs are:
On examination, he is in acute distress with diffuse wheezing and urticaria are noted on his abdomen and chest.
What is the immediate first-line management?
Correct Answer: E
The patient is experiencing anaphylaxis secondary to a rituximab infusion, as evidenced by bronchospasm, urticaria, and hypotension following the initiation of his second exposure to the medication. Epinephrine should be injected by the intramuscular (IM) route up to a dose of 0.5 mg as soon as anaphylaxis is recognized. This route achieves peak plasma concentrations quickly and reliably. Epinephrine has historically been labeled based on dilution, leading to confusion among providers. A dilution of 1:1000 refers to 1 mg/mL concentration. Therefore, to administer 0.5 mg, one administers 0.5 mL IM (answer E is correct; answers B, C, and D are incorrect). Intravenous epinephrine is reserved for refractory shock despite initial treatment and aggressive fluid administration. As anaphylaxis induces rapid vasoplegia and vascular leak, aggressive IV crystalloid resuscitation should be administered in the hypotensive patient. Diphenhydramine, H2 histamine antagonists, glucocorticoids, and inhaled beta-2 agonists are adjunctive therapies for anaphylaxis (answer A is incorrect).
A 65-year-old woman with a history of nonischemic cardiomyopathy is admitted for dyspnea and progressive edema to the medical ward. On admission, her medications include lisinopril, carvedilol, and aspirin. She receives 80 mg of IV furosemide and makes a total of 30 mL of urine over the next 8 hours. Her creatinine is increased from a baseline of 1.2 to 2.5 mg/dL, her lactate is elevated at 4 mmol/L, and her hemoglobin is stable at 12 mg/dL. Her nurse reports progressive disorientation and somnolence. On examination, her vitals are:
Her extremities are edematous and cool, pulses are weak, and an S3 is auscultated. An electrocardiogram (EKG) does not show any changes compared with baseline. Beside echocardiogram reveals severe diffuse left ventricular (LV) hypokinesis without evidence of effusion or significant right ventricular dysfunction. She is transferred to the ICU. A central venous catheter is placed, and her central venous oxygen saturation (CVO2 ) is 30%.
What is the best next step in management?
Correct Answer: C
This patient is in cardiogenic shock as evidenced by clinical examination, evidence of progressive end-organ dysfunction, hypotension, and low CVO2 . Her bedside echocardiogram supports this diagnosis and notably lowers the probability of other low output states including tamponade or right heart failure from PE. Her clinical examination and laboratory values do not support hypovolemia or hemorrhage. The goals of therapy for this patient include increasing cardiac contractility, decreasing systemic vascular, and relieving volume overload. The initial management in the setting of shock should focus on the immediate restoration of end-organ perfusion, which is facilitated with inotropic support with dobutamine, a B1 receptor agonist, or milrinone, a phosphodiesterase 3 inhibitor (answer C is correct). Administration of IV fluid will not improve the cardiac output for this patient and will result in further evidence of hydrostatic edema including pulmonary edema (answer A is incorrect). Heparin is indicated in acute coronary syndromes and venous thrombosis, neither of which is apparent in this patients evaluation (answer B is incorrect). In cases of bradyarrhythmia from beta-blocker overdose, glucagon may be used for reversal; however, the patient’s HR of 80 beats per minute is unlikely to be the cause of cardiogenic shock (answer D is incorrect). Loop diuretic efficacy depends on delivery to the site of action within the ascending limb of the loop of Henle. When cardiogenic shock results in a decreased glomerular filtration rate (assumed to be approaching zero in an oliguric patient), drug delivery is significantly decreased. In conjunction with inotropic support and afterload reduction, higher doses of diuretic medications will be required to achieve adequate concentration at the drug target but are unlikely to be effective in isolation (answer E is incorrect).
A 65-year-old man with a history of heavy alcohol use presents to the emergency department with severe abdominal pain and is diagnosed with alcoholic pancreatitis. He is noted to have a BP of 70/40 mm Hg after receiving 3 L of IV normal saline and is admitted to the ICU for management of severe pancreatitis and shock. On ICU day 1 and 2, his blood glucose levels are noted to be greater than 250 mg/dL on multiple consecutive measurements.
Which of the following statements regarding glycemic control in critically ill adults is correct?
Both hyperglycemia and hypoglycemia are associated with worse clinical outcomes in critically ill patients based on the results of multiple prospective randomized trials and retrospective data. Hyperglycemia is variably defined as glucose measurements greater than 180 mg/dL or 200 mg/dL. Hypoglycemia is typically a blood glucose less than 80 mg/dL. Literature on hyperglycemia is mainly retrospective and describes an association with increased mortality in a variety of patient populations including critically ill medical and surgical patients. Multiple prospective randomized controlled trials have examined intensive insulin therapy to target strict glucose control, typically 81 to 110 mg/dL, compared with conventional glucose control. These studies have demonstrated that intensive insulin therapy results in a higher rate of hypoglycemia, which is the most common adverse effect, and thereby increased mortality. Currently, it is recommended to maintain blood glucose of 140 to 180 mg/dL to avoid dangerous hypoglycemia or hyperglycemia (answer C is correct).
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