Fluids, Hemstasis, Transfusion, Shock

Question 1

Remarks on hypocalcemia

Answer 1

Possible causes:
-pancreatitis
-hypoparathyroidism
May cause:
-decreased cardiac contractility
-heart failure
-prolonged QT
-T wave inversion
-heart block
-ventricular fibrillation (not atrial fib)

Question 2

ECG changes in hyperkalemia

Answer 2

Peaked T waves (early chage)
Flattened P wave
Prolonged PR (first degree block)
Widened QRS
Sine wave 
Ventricular fib

Question 3

Remarks on albumin in fluid res

Answer 3

Available as 5% (osm of 300mOsm/L) or 25% (osm of 1500 mOsm/L)
May lead to pulmonary edema when used as resuscitation for hypovolemic shock

Question 4

Remarks on TBW of neonatewts

Answer 4

Highest % of TBW found in newborns, with ~ 80% TBW composed of water. This decreases to about 65% by 1 year and thereafter remains fairly constant

Question 5

Ho to correct potassium for alkalosis

Answer 5

Potassium decreases by 0.3mEq/L for every 0.1 increases in pH above normal

Question 6

Water deficit

Answer 6

Water deficit (L) = [(serum sodium-140)/140] x TBW
📌p69

Question 7

Calcium and albumin

Answer 7

Total serum calcium goes down 0.8mg/dL for every 1g/dL decrease in albumin

Question 8

Albumin rv

Answer 8

3.5-5.5 g/dL

Question 9

Calcium rv

Answer 9

Total calcium:
8.6-10.0 mg/dL
(2.15-2.50 mmol/L)
Ionized calcium
4.6-5.3 mg/dL
(1.16-1.32 mmol/L)

Question 10

Corrected AG

Answer 10

Actual AG + [2.5(4.5-albumin)]

Question 11

Eponym for factor X`

Answer 11

Stuart factor

Question 12

Other name for factor XI

Answer 12

Plasma thromboplastin antecedent (PTA)

Question 13

Which congenital factor deficiency is assc’d with delayed bleeding after initial hemostasis

Answer 13

Factor XIII

Question 14

In a previously unexposed patient, when does the platelet cout fall in HIT?

Answer 14

5-7 days

*if re-exposure: within 1-2 days

Question 15

Describe HIT

Answer 15

A form of drug-induced immune thrombocytopenia (ITP)

Antibodies vs platelet factor 4 (PF4) are formed during exposure to heparin

Question 16

Which of the following is the most common intrinsic platelet defect?

Answer 16

Storage pool disease

• dense granule deficiency is most prevalent
• storage site of ATP, ADP, Ca++, iphosphate
• may be an isolated defect or occur with partial albinism in the HERMANSKY-PUDLAK SYNDROME
• bleeding is primarily caused by the decreased release of ADP

Question 17

An isolated defect of the alpha granules is known as

Answer 17

Gray platelet syndrome

Question 18

Remarks on allergic blood transfusion reactions

Answer 18

Occurs in ~1% of all transufsions

May occur in any blood product, but are commonly assoc’d with FFP and platelets

Question 19

What is the risk of HCV and HIV-1 transmissiosn with blood tranfusion?

Answer 19

1:1,000,000

Question 20

What is the risk of HBV transmission with blood transfusion

Answer 20

1:300,000

Question 21

Remarks on FFP

Answer 21

Required for the transfusion of facctor VIII or V (proaccelerin)

Question 22

The most common clinical manifestation of a hemolytic transfusion reaction

Answer 22

Oliguria (58%)

Hemoglobinuria (56%)

Question 23

Bank blood is appropriate for replacing each of the ff EXCEPT

Answer 23

Factor VIII

-labile, and 60-80% of activity is gone 1 week after collection

Question 24

Remarks on volume receptors in the heart

Answer 24

Sensitive to changes in both chamber pressure and wall strtch, and are present within the atria of the heart.
They beome activated with LOW volume hemorrhage or mild reductions in RIGHT atrial pressure

Question 25

Remarks on baroreceptors

Answer 25

Respond to LARGER reductions in intravascular volume These receptors normally INHIBIT induction of ANS. When activated, these baroreceptors diminish their output, thus DISINHIBITING THE EFFECT OF THE ANS

Question 26

Remarks on colloid solutions

Answer 26

Increase extracellular fluid deficit Ionized fraction of serum calcium is decreased Immunoglobulins drop Reaction to tetanus toxoid given to the patient suffering form major trauma is decreased Endogenous production of albumin also decreases

Question 27

Remarks on tumor necrosis factor alpha (TNF-a)

Answer 27

Can be released as a response to bacteria or endotoxin Peak within 90 mins of stimulation, and return to baseline within 4 hours Leads to development of shock and hypopefusion Contributes to muscle protein breakdown and cachexia Levels in trauma are far less

Question 28

Stab wound, hypotensive, markedly tachycardic, and appears confused. What percent of blood volume has he lost

Answer 28

>40%

Question 29

Most frequently encountered form of vasodilatory shock

Answer 29

``` SEPTIC SHOCK Other causes: -hypoxic lactic acidosis -carbon monoxide poisoning -decompensated and irreversible hemorrhagic shock -terminal cardiogenic shock -postcardiotomy shock ```

Question 30

In septic shock, what is often given to patients with hypotension refractory to norepinephrine

Answer 30

Arginine vasopressin

Question 31

Remarks on cardiogenic shock

Answer 31

Sustained hypotension (SBP<90) for at least 30 mins Reduced cardia index (<2.2L/min per square meter) Elevated pulmonary artery wedge pressure (>15mmHg) Mortality rates are 50-80% MCC: acute extensive MI Cardigenic shock compolicates 5-10% of acute MI Most common cause of death in patients hospitalized with acute MI *typically not found on admission *75% of patients who have cardiogenic shock complicating acute MIs develop signs of cardiogenic shock within 24 hours after onset of infarction (average 7 hours)

Question 32

Corticosteroids in the treatment of septic shock

Answer 32

Improves mortality in patients with relative adrenal insufficiency *no benefit in the intent of shock reversal

Question 33

Remarks on serum lactate

Answer 33

Metabolized by the liver (50%) and kidneys (30%) Indirect measure of magnitude and severity of shock Prognostic factors: 1. Admission lactate level 2. highest lactate level 3. Time interval to normalize the serum lactate 100% survival if normalized withtin 24 hours 78% survival if normalized bet 24 and 48 horuos 14% survival if > 48 hours