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Shock Questions

CASE 1

A 17 year old girl with juvenile rheumatoid arthritis presents with new and profound
weakness. She is being treated with naproxyn and methotrexate. She has taken no
prednisone in more than one year. She denies localizing symptoms or change in stools
but does admit to shortness of breath at rest and has had low-grade fevers for 3 days. On
examination she is pale and lethargic. BP 88/66; HR 96; RR 24; T 38.2; SpO
2
95%.
Capillary refill is delayed, neck veins are distended to the angle of the jaw at 30, the
lungs are clear, there is no S
3
, the abdomen is slightly distended but nontender, and there
is trace bipedal edema but no calf tenderness.

1. Which one of the following is most likely to raise the cardiac output in the next 30
minutes?

A. Normal saline, 2L wide open
B. Hydrocortisone 300mg IVP
C. Hydralazine 10mg slow IVP
D. Tobramycin plus a 3
rd
generation cephalosporin
E. None of the above


2. You place a left subclavian central venous catheter and find that the central
venous oxyhemoglobin saturation (ScvO
2
) is 36%. Which one of the following best
explains this finding?

A. Malposition of the catheter, perhaps up the left jugular vein
B. Shock due to cardiac pump dysfunction
C. Incipient pulmonary edema
D. Sepsis, which increases oxygen consumption
E. Hypercapnia

3. Taking into account the findings above, which one of the following sets of
hemodynamic data is most likely to be obtained in this patient?


Pra (mmHg) Prv (mmHg) Ppa (mmHg) Ppw (mmHg) Q
T
(L/min) SvO
2

A. 17 30/17 30/19 18 1.9 0.41
B. 17 48/17 48/28 24 8.2 0.39
C. 5 52/6 52/11 10 2.1 0.40
D. 4 20/4 20/8 7 5.0 0.72
E. 12 50/12 50/22 10 4.8 0.70


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4. Assuming the data from Question 3 pertain to this case, which of the following is
the best diagnosis?

A. Septic shock
B. Right ventricular infarction
C. Cardiac tamponade
D. Massive pulmonary embolism
E. Papillary muscle rupture


CASE 2
A 30 year old intravenous drug abuser admitted with tetanus is intubated and
mechanically ventilated for severe respiratory distress. The following central venous
pressure tracing is displayed on the bedside monitor.




5. What is the central venous pressure (mmHg)?

A. 35
B. 30
C. 16
D. 0
E. None of the above

CASE 3

A 77 year old man with chronic bronchitis is admitted with cough, fever, rigors, and
purulent sputum. He was hospitalized one month ago for diverticulitis. Clinical
examination and chest radiograph are consistent with right upper lobe pneumonia. He is
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given oxygen and antibiotics but 6 hours after admission he becomes agitated and
markedly dyspneic. Following intubation and sedation: BP 80/40; HR 115; RR 36 (vent);
and T 39.8. The ventilator is set on volume assist-control at 26/min, V
T
400cc, PEEP 10,
FiO
2
0.6 and ABG is PO
2
69 (SaO
2
= 95%); PCO
2
43; pH 7.24. The white blood cell
count is 23,000 with 20% bands, the hemoglobin is 9.9 g/dL and platelet count is 68,000.
The creatinine is 2.2. The central venous pressure is 5 mmHg and the ScvO
2
is 49%.

6. Which one of the following is the most appropriate next step?

A. Infuse norepinephrine, 6 mcg/min IV
B. Begin vasopressin, 40 mU/min
C. Infuse normal saline, 1 L rapidly
D. Place a pulmonary artery catheter
E. No hemodynamic therapies are indicated

7. Blood cultures show gram positive cocci in clusters. Ventilator settings are
unchanged as is the SpO
2
. On infusions of norepinephrine and vasopressin, BP
98/44; HR 122; RR 28; ScvO
2
77%, and CVP 13 mmHg. Urine output is only 20
cc/hr. His admission chest x-ray is shown below. Which one of the following is the
most appropriate next step?
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A. Give methylprednisolone, 250mg IVPB
B. Diagnostic thoracentesis
C. Order maintenance IV fluids at 250 cc/hr
D. Tube thoracostomy
E. Infuse low-dose dopamine (2 mcg/kg/min)



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CASE 4

You are called at home for your opinion regarding a newly admitted, critically ill patient
who is comatose and ventilated with BP 90/60; HR 138; RR 36 (vent); T 35.1. Your
colleague has placed a PAC and reports the following hemodynamics: Pra 16; Prv 43/28;
Ppa 58/22; Ppw 4. The cardiac output is not yet available.

8. What best explains these hemodynamics?

A. Hypovolemia
B. Acute pulmonary embolism
C. Neurogenic shock
D. Valvular dysfunction
E. Measurement error


CASE 5

A 22 year old woman with severe asthma fails noninvasive ventilation but stabilizes
initially after intubation and mechanical ventilation. She is given bronchodilators and
corticosteroids for status asthmaticus and is deeply sedated and pharmacologically
paralyzed. On volume assist-control V
T
700; RR 18; PEEP 5; FiO
2
0.5 the PCO
2
is 52;
pH 7.29. You increase the V
T
to 800 and RR to 26 and the PCO
2
falls to 43. SpO
2
is
0.98. The initial chest radiograph shows hyperinflated lungs, no infiltrates, and an
endotracheal tube and right internal jugular catheter in good position. You are called
back to the bedside for new hypotension and find BP 70/45; HR 138; T 36.3; CVP 11
mmHg.

9. Which one of the following is least likely to improve the blood pressure?

A. Reduce the PEEP to 0
B. Reduce the V
T
to 400
C. Reduce the RR to 18
D. Give 2 L Lactated Ringers
E. Disconnect the ventilator


10. Two minutes after disconnecting the ventilator, the blood pressure has fallen to
60/40 and the heart rate is 160/min. The CVP is now 13 mmHg. Which one of the
following is the most appropriate next step?

A. Order a STAT chest radiograph
B. Infuse t-PA, 100mg over 2h
C. Increase the tidal volume to 1000cc
D. Place catheters into the 2
nd
interspace, midclavicular line
E. Begin dopamine, 10 mcg/kg/min
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CASE 6

A 55 year old man with morbid obesity (BMI 40) is recovering from a total hip
arthroplasty. On post operative day 3, his nurse notes him to develop acute dyspnea. His
vital signs are: Temp 37.8, HR 110, RR 35, BP 80/65. On physical exam he states that
he is breathless. His heart exam shows tachycardia without an audible murmur. His
lungs are clear. His extremities are cool with delayed capillary refill. His CVP is 26 and
the waveform shows no respiratory variation. An arterial blood gas on face mask oxygen
shows pH 7.30, PCO
2
40, PO
2
175. An emergent echocardiogram shows right ventricular
dilation with interventricular septal bowing into the left ventricle. The left ventricular
cavity is small.

11. All of the following are indicated except:

A. Endotracheal intubation and mechanical ventilation with assist control
mode
B. Administration of norepinephrine and dobutamine infusions
C. Administration of intravenous unfractionated heparin for full systemic
anticoagulation after discussion with the orthopedic surgeon
D. Administration of 1 liter bolus of normal saline
E. Arranging for CT angiography to evaluate for pulmonary embolism once
the patient is stabilized

Case 7

A 49 year old woman with acute myelogenous leukemia is in the ICU with neutropenia,
ascending cholangitis and septic shock. Upon admission from the emergency room, she
was resuscitated with intravenous crystalloid, broad spectrum antibiotics and
endotracheal intubation for her shock. Twenty four hours after admission to the ICU, she
is noted to be hypotensive again. Her vital signs are: Temperature 37.2
o
C, HR 110, BP
80/ 40, RR 20 and she has been oliguric over the past four hours. Her chest x ray shows
no evidence of parenchymal airspace opacities. Her CVP is 6 mm Hg. Her laboratory
values reveal: Na 141, K 4.2, Cl 101, HCO3
-
17, BUN 35, Creatinine 1.9, WBC 17.2
(15% bands), Hemoglobin 8.1 and S
cv
O
2
66%. The patient is 5 feet, 5 inches tall and
weighs 60 kg. Her ventilator settings are: Assist control, tidal volume 650 mL,
respiratory rate 20, FiO2 50%, PEEP 5. The patient is sedated and appears comfortable
on mechanical ventilation. An arterial catheter tracing is shown below.


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12. The most appropriate management of her shock is:

A. Rapid intravenous crystalloid bolus at 500 mL intervals to increase her
CVP to 8-12 mm Hg
B. Transfusion of two units packed red blood cells
C. Norepinephrine infusion at 0.75 mcg/kg/minute
D. Rapid intravenous crystalloid bolus to increase her S
cv
O
2
to greater
than 70%





























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Case 8

A 62 year old woman with alcoholic cirrhosis is in the ICU with aspiration pneumonia
and severe ARDS. Details of her past medical history are not available, though a friend
states she has bad arthritis and takes medication under the direction of a rheumatology
specialist. Her morning arterial blood gas shows: pH 7.33, pCO2 30, pO2 67. That
afternoon, ninety six hours after admission to the ICU, the bedside nurse calls reporting
concerning sudden changes in her vital signs: Temperature 37.5
o
C, HR 135, BP 80/68,
RR 33, SpO2 86%. Her extremities are cool with delayed capillary refill. Her CVP is 23
mm Hg. Her morning CXR is shown below. Her laboratory values reveal: pH 7.21, pCO2
31, pO2 64, S
cv
O
2
55%. Her ventilator settings are: Assist control, tidal volume 600 mL,
respiratory rate 20, FiO2 50%, PEEP 12.





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13. The most appropriate next step in the management of her shock is:

A. Intravenous crystalloid bolus of 1000 mL
B. Tube thoracostomy
C. Dobutamine infusion at 5 mcg/kg/minute
D. Hydrocortisone 100 mg IVP