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Flashcards in Chapter 5: Shock Deck (10):
1

A 72 year old man in the intensive care units develops the sudden onset of agitation and hypertension (180 mm Hg systolic) 6 hrs after an open abdominal aortic aneurysm repair. He receives a dose of narcotic analgesic and 10 minutes later he has a blood pressure of 90 mm Hg systolic. Pulmonary artery catherter information at this time : Cardiac Index 1.81/min/m2, CVP 28 mm Hg, PAOP 32 mm Hg, systemic vascular resistance 1500 dynes/sec/cm5. An EKG shows ischemia. He is still intubated and on a ventilator. His hemodynatmic state is best characterized as:

Cardiogenic Hypoperfusion

2

A 59 year old woman is in the intensive car unit following emergency surgery for perforated diverticulitis. In the Emergency Department her admission blood pressure was 90/60 mm Hg, pulse 120/min, temperature 38.8 degrees Celsius, oxygen saturation 95% on 4L of nasal oxygen. Her usual blood pressure is 140/70 mm Hg. She received three liters of lactated Ringers solution, ciprofloxacin and metronidazole, and was taken for emergency sigmoid resection, end sigmoid colostomy and hartmann’s puch. During the procedure her systolic was rarely above 100 mmHg despite admin of neosynephrine. She reicved 6 more liters of LRs as well as 500cc of hetastarch during the 2 hr procedure and made 60 cc of urine.
Upon arrival in the ICU a Central venous cath is placed and following data retrieved: MAP 60 mmHg on neosynephrine, CVP 8mmHg, CV sat 55%, arterial blood gas: pH 7.3, pO2 75 on FIO2 60% - PEEP 7.5 ccH2O, pCO2 36 mmHg. Arterial lactice acid 4.2 umol/L.
The principle value of lactic acid measurement for this pt is as a marker of:

Response to circulatory resuscitation

3

A 65 year old man is being admitted to the surgical intensive care unit following an elective aortofemoral bypass for bilateral aortoiliac occlusive disease. The intraoperative course was notable for one episode of hypotension (80 mm Hg systolic) when the aortic clamp was released that lasted for about 10 minutes. He has a history of coronary artery disease with stable anginga and a negative stress prior to the surgery. When he arrives in the ICU his BP is 130/80 mmHg, P 95/min, and following data measured and calculated from pulmonary artery catheter placed during the surgery: Cardiac index 2.8 l/min/m2, CVP 16 mmHg, PAOP 18 mm Hg, SVR 950 dynes/sec/cm5. His hemodynamic state is best designated as:

Euvolemic, normal perfusion

4

A 43 year old man was admitted to the intensive car unit 36 hours earlier for a diagnosis of severe alcohol- induced pancreatitis. He weight 70 kg on admission. His mean arterial pressure throughout this time has been less that 65 mm Hg, His urine output has been less that 30 ml/hour, and his poor respiratory status has resulted in mechanical ventilation. His fluid balance is fifteen liters positive and his abdomen is noted to be tense with an abd pressure of 30 mmHg. The principle cause of his ongoing HoTN is decreased:

Venus Return

5

A 45 year-old man comes to the Emergency Department with a complaint of upper abdominal and back pain of 12 hours duration. He was admitted to the hospital 3 weeks ago for alcoholic withdrawal. Today he vomited green looking material several times. He denies hematemesis, diarrhea, bloody bowel movements, and liver disease. He is not diabetic. His temp is 38.6 and BP 90/60 mmHg, pulse 120/min, RR 26/min w/ O2 sat 92% of 4L nasal O2. PE shows agitated middle-aged male who is pale w/ cyanotic fingers. He is disoriented toplaceanddate.Chestisclear,neckveinsflat,heartisw/omrg. Hisabdomenshowsepigastricdistention and no scars or bulges. He has no bowel sounds. He has percussion tenderness and involuntary guarding in the epigastrium. His hands and feet are cyanotic and cold. Passage of bladder cath returns 100 cc of dark urine. Labortary data are: (see table)

Plain XR of chest and abdomen are unreavealing. An abdominal CT scan shows a markedly enlarged, edematous pancreas with several per pancreatic fluid collections. The therapy that would be most specific for the circulatory disorder in this patient is administration of: ?

Three Liters of isotonic crystalloid

6

A 35-year-old woman is in the intensive care unit 48 hours after admission for severe gallstone induced pancreatitis. When she was in the Emergency Department her blood pressure was 95/60 mm Hg, pulse 120/min, and respiration 22/min. Her oxygen saturation was 90% on room air, hemoglobin was 15 mg/dL and WBC was 18,000/mm3. Her blood pressure sugar was 250 mg/dL and she is not a known diabetic.
Over the past 48 hrs, efforts to maintain a urine output of 30-40 cc/hr are accompanied by a 10kg gain in weight, sequestration of 12L of fluid, as well as intubation and mechanical ventilation (FIO2 50%, 7.5 PEEP) to maintain arterial O2 sat >90%. Now her BP is 95/60 mmHg and pulse is 110/min. Her abd is distended with no bowel sounds. The extremitites are warm with brisk capillary refills.
Lab studies: hgb – 10.5, WBC 20K, BUN and Cr have from 30 mg/dl and 1.5mg/dL to 35 and 1.8, respsectively. Total Ca is 6.0 mg/dL and ionized Ca is 0.98 umol/L. A pulmonary artery cath is placed and the following data measured or calculated: Cardiac index – 4.8 l/min/m2, CVP 18 mmHg, pulmonary artery pressure 35/22 mmHg, PAOP 15 mmHg, SVR 600 dynes/sec/cm5. Her hemodynamic state is best characterized as:

Hyperdynamic Perfusion

7

A 55-year-old man is in the hospital 3 days following an open cholecystectomy for acute cholecystitis. He has been ill at home for 2 days before seeking medical attention and was operated on the fay following admission. During induction of anesthesia his systolix pressure fell from his usual 150-160 mm Hg range to 110 mm Hg and remained at the level for the first 30 minutes of the case. During the procedure the GB was torn and bile spilled into the abdomen. Culture of bile recovered E. coli and Klebsiella species. His fascia was closed and skin left open. His ionized Ca during the procedure was 1.00 umol/L. He was continued on ampicillin-sulbactam that was started b/f the procedure. During his last two days he sequestered 4 and 2.5 L of fluid. His systolic BP has been mostly 140-170 mmHg, pulse 80-90s/min. He was started on a -blocker the day before surgery and this was continued post op. On morming rounds he is noted to be dyspneic w/ O2 sat 98% on 40% facemask, and a RR of 26-30/min. His BP is 180 mmHg systolic. On exam he is sitting upright. His neck veins are distended, crackles are heard throughout both lungs, and his heart has a gallop. His abdomen is mildly distended w/ bowel sounds. His wound is unremarkable. His extremetiies are cool, his hands and feet are cyanotic. The principle cause of his hemodynamic state is decreased

Cardiac Contractility

8

A 43-year-old woman is in the intensive care unit for hypotension and respiratory failure. On admission yesterday, her blood pressure was 70/40 mm Hg, pulse 130/min, respirations 26/mins, and temperature 40 degrees Celsius. Over the last 24 hours she received 12 liters of isotonic crystalloid infusion, as well as infusions of norepinephrine and vasopressin in an effort to maintain her mean arterial pressure > 65mm Hg. Her chest radiograph shows consolidation in the left upper lobe. Sputum sample and four out of four blood cultures at 24 hrs show G+ cocci in chains. She is receiving broad-spec PCN. Her hgb was 13.6 mg/dL on admission has risen to 15.5 mg/dL. Her WBC that was 3600/mm3 on admission has increased to 12000/mm3. The principle reason for the increase in hgb is plasma volume depletion from:

Diffuse interstitial fluid accumulation

9

A 20-year-old male driver is brought to the Emergency Department following a motor vehicle crash. He was the driver and was not wearing a seat belt. He is on a backboard with a hand cervical collar in place. He is receiving nasal oxygen at 4 liter/min. He is speaking and complaining of chest pain and shortness of breath. His blood pressure is 90/60 mm Hg, pulse 130/min. He has ecchymosis and abrasions over his right chest. There are no breath sounds in the right chest. His O2 sat is 85%. He has cool, cyanotic extermiites. Removal of his neck collar with in-line traction of his head reveals distended neck veins. The principle cause of decreased HTN?

Venous return

10

A 65-year-old woman is in the intensive care unit following emergency surgery for perforated divericulitis. In the Emergency Department her admission blood pressure was 90/60 mm Hg, pulse 120/min, temperature 38.8 oxygen saturation 95% on 4L of nasal oxygen. Her usual blood pressure is 140/70 mm Hg. She received 3 liters of lactated Ringers solution, ciprofloxacin, and metronidazole, and was taken for emergency sigmoid resection, end sigmoid colostomy, and Hartmann’s puch. During the procedure her systolic was rarely above 100 mmHg despite the dminstration of neosynephrine. She received 6 more liters of lactated Ringers as well as 500cc of hetastarch during the 2hr procedure and make 60 cc of urine.
Upon arrival in the ICU, a central venous cath is placed and following data retrieved: MAP 60 on neosynephrine, CVP 8 mmHg, CV saturation 55%.
ABG: pH 7.30, PaO2 75 on FIO2 60%-PEEP 7.5 ccH2O , pCOw 36 mmHg
Arterial lactic acid: 4.2 umol/L
Her hemodynamic state is best characterized as:

Hypovolemic Hypoperfusion