11
Cardiopulmonary Resuscitation, Oxygen Delivery and Shock
Kevin W. Cahill, MD, Harsh Desai, MD, and Luis Cardenas, DO, PhD
Department of Surgery, Christiana Care Health Care System, Newark, DE, USA
1 A 72-year-old woman with a history of Child’s B cir-
rhosis and supraventricular tachycardia is in the ICU
following laparotomy for strangulated ventral hernia.
She begins to complain of rapid heartbeat and is noted
to be in an irregular, wide-complex ventricular tachy-
cardia on EKG. She maintains pulse and adequate
blood pressure. Which of the following is the best ini-
tial therapy to administer?
A Synchronized cardioversion.
B Adenosine 6 mg IV.
C Amiodarone 150 mg IV.
D Defibrillation.
E Vagal maneuvers.
The 2020 ACLS guidelines differentiate between regular
and irregular wide-complex tachycardia with and with-
out pulse. In this instance, the patient is in an irregular
wide-complex tachycardia, symptomatic, but stable as
evidence by pulse and pressure. Given this hemodynamic
stability, synchronized cardioversion and defibrillation
are not the initial therapies (choices A, D). Adenosine and
vagal maneuvers may be effective in regular ventricular
tachycardia (choices B, E). Therefore, amiodarone is the
best initial medication to administration often followed
by infusion (choice C). Individuals with hemodynami-
cally unstable ventricular tachycardia should not initially
receive amiodarone. These individuals should be cardio-
verted. Amiodarone can be used regardless of the indi-
vidual’s underlying heart function and the type of
ventricular tachycardia. It can be used in individuals with
monomorphic ventricular tachycardia, but is contraindi-
cated in individuals with polymorphic ventricular tachy-
cardia as it is associated with prolonged QT intervals,
which will be made worse with anti-arrhythmic drugs.
Amiodarone is categorized as a class III anti-arrhythmic
Surgical Critical Care and Emergency Surgery: Clinical Questions and Answers, Third Edition.
Edited by Forrest “Dell” Moore, Peter M. Rhee, and Carlos J. Rodriguez.
© 2022 John Wiley & Sons Ltd. Published 2022 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/surgicalcriticalcare3e
agent, and prolongs phase 3 of the cardiac action poten-
tial. Amiodarone slows conduction rate and prolongs the
refractory period of the SA and AV nodes. It also pro-
longs the refractory periods of the ventricles, bundles of
His, and the Purkinje fibers without exhibiting any effects
on the conduction rate. Serious side effects include inter-
stitial lung disease and liver dysfunction with elevated
liver enzymes.
Answer: C
Littmann L, Olson EG,Gibbs MA. Initial evaluation and
management of wide-complex tachycardia: a simplified
and practical approach. Am J Emerg Med. 2019; 37:
1340–1345.
Panchal AR, Bartos JA, Cabanas JG et al. Part 3: Adult
basic and advanced cardiac life support: 2020 American
Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care.
Circulation. 2020; 142 (suppl 2): S366–S468.
2 Which of the following techniques has not been shown
to be effective in airway management during cardiac
arrest?
A Head tilt – chin lift
B Jaw thrust
C Cricoid pressure
D Nasopharyngeal airway
E Oropharyngeal airway
Of the above maneuvers, cricoid pressure has not been
shown to be effective during airway management in car-
diopulmonary resuscitation. It may impede ventilation
or placement of airway adjuncts such as a supraglottic
airway as well as contribute to increased airway trauma.
12 Surgical Critical Care and Emergency Surgery

Jaw thrust is preferred in patients with suspected spinal
injury. Nasopharyngeal and oropharyngeal airways are
particularly useful in cases of facial trauma though care
must be taken with possible basilar skull fractures.
Answer: C
Carauna E, Chevret S, Pirracchio R. Effect of cricoid
pressure on laryngeal view during prehospital tracheal
intubation: a propensity-based analysis. Emerg Med J.
2017; 34 (3): 132–137.
Panchal AR, Bartos JA, Cabanas JG et al. Part 3: Adult
basic and advanced cardiac life support: 2020 American
Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care.
Circulation. 2020; 142 (suppl 2): S366–S468.
3 In a patient experiencing PEA arrest, which of the fol-
lowing would not be a likely etiology?
A Hypoglycemia
B Hypoxia
C Hypovolemia
D Hypokalemia
E Hypocalcemia
Pulseless electrical activity is so named due to evidence
of cardiac mechanical activity on echocardiogram or
rhythm on EKG. The algorithm is similar to the asystole
algorithm utilizing compressions and epinephrine. The
traditional etiologies are described as “Hs” and “Ts.” The
4 Which of the following is the minimum chest compres-
sion fraction (defined as amount of time spent deliver-
ing chest compressions during CPR) shown to be
associated with improved survival?
A 0–20%
B 21–40%
C 41–60%
D 61–80%
E 81–100%
Optimal outcomes have been demonstrated with mini-
mal pauses between compressions for pulse checks and
breaths given during high-quality CPR. A compression
fraction of at least 60% has been shown to be necessary
for best outcomes. Animal studies previously conducted
have demonstrated decreased coronary and cerebral
perfusion when chest compressions are not being con-
ducted resulting in worsened outcomes. Multiple retro-
spective analyses and cohort studies have resulted in
many emergency agencies targeting a compression frac-
tion of between 60 and 80% as a quality metric. This
involves delivery of high-quality compressions of appro-
priate depth, 2 inches, and rate, at least 100/min.
50% Final vital status by CCF category
40%

“Hs” include hypoglycemia, hypoxia, hyper/hypoka- 29%

25%
lemia, hypovolemia, acidosis, and hypothermia.
23% 25%
Hypocalcemia can present with muscular and neuro-
logic symptoms such as perioral numbness, cramping,
Percentage surviving

30%
fatigue, seizures, and irritability. Hypocalcemia may also
be associated with increased risk of arrhythmias, but is
not typically considered high on the initial differential of
PEA arrest. The “Ts” taught as etiologies include tension
pneumothorax, cardiac tamponade, toxins, pulmonary 20%
12%
thrombosis, or coronary thrombosis. Evaluation for
pneumothorax or tamponade includes rapid bedside
physical exam as well as point of care ultrasound for rule
out. Ultrasound may also reveal signs of thrombosis with 0%
right ventricular enlargement or free-floating thrombus.
Answer: E

Andersen LW, Holmberg MJ, Berg KM et al. In hospital 0%

cardiac arrest: a review. JAMA. 2019; 321 (12): 0% – 20% 21% – 40% 41% – 60% 61% – 80% 81% – 100%
n = 100 n = 74 n = 117 n = 143 n = 72
1200–1210.
Panchal AR, Bartos JA, Cabanas JG et al. Part 3: Adult CCF category

basic and advanced cardiac life support: 2020 American Answer: D

Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care. Christenson J, Andrusiek D, Everson-Stewart S et al. Chest
Circulation. 2020; 142 (suppl 2): S366–S468. compression fraction determines survival in patients

with out of hospital ventricular fibrillation. Circulation.
2009; 120: 1241–1247.
Panchal AR, Bartos JA, Cabanas JG et al. Part 3: Adult
basic and advanced cardiac life support: 2020 American
Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care.
Circulation. 2020; 142 (suppl 2): S366–S468.
5 Which of the following is considered the highest pre-
dictor of survival for in- and out-of-hospital CPR?
A Age.
B Shockable rhythm.
C Arrest at home.
D Arrest at night vs during the day.
E Delayed EMS response time.
On the whole, survivability is dependent on patient, system,
event, and therapeutic factors. With increasing comorbid-
ity and age, survivability decreases. System factors include
time to arrival of EMS, time to initiation of CPR, and time
to defibrillation. Event factors include preceding symptoms.
Finally, therapeutic factors include availability of medica-
tions to treat suspected cause, time to ER, time to cath lab
should it be required, etc. The greatest mortality risk with
out of hospital cardiac arrest stems from unwitnessed
arrests without bystander CPR often occurring at night in
the elderly. Highest survivability stems from witnessed
arrests with rapid initiation of bystander CPR and initial
shockable rhythm, such as ventricular fibrillation.
Answer: B
Myat A, Song K-J, Rea T. Out of hospital cardiac arrest:
current concepts. Lancet. 2018; 391: 970–79.
Navab E, Esmaelli M, Poorkhorshidi N et al. Predictors of
out of hospital cardiac arrest outcomes in pre-hospital
settings; a retrospective cross-sectional study. Arch Am
Emerg Med. 2019; 7 (1): e36.
6 A 70-year-old man is 2  weeks status-post laparo-
scopic sleeve gastrectomy and he undergoes witnessed
cardiac arrest at home after complaint of new onset
chest pain. Bystander CPR achieves ROSC after
10 minutes. He is now in the ICU, intubated, and on
vasopressors for associated hypotension. Which of the
following interventions has the strongest associated
survival benefit in post-arrest care according to cur-
rent resuscitation guidelines?
A Maintain 100% FiO2.
B Pursuit of cardiac intervention when STEMI
identified.
C Use of corticosteroids.
D Targeted temperature management to prevent fever.
E Seizure prophylaxis.
Cardiopulmonary Resuscitation, Oxygen Delivery and Shock 13
If a cardiac cause is suspected, pursuit of cardiac inter-
vention such as with percutaneous coronary interven-
tion (PCI) is strongly recommended. Hyperoxygenation
therapy, the use of corticosteroids, and seizure prophy-
laxis have thus far shown no survival benefit (choices A,
C, and E). Finally, targeted temperature management is
currently recommended for post-arrest care with target
of 32–36°C. This is based on several studies showing
potential neurologic benefit. Preventing fever has not yet
been proven to improve outcome though the 2020 AHA
guideline (choice D). Ischemic heart disease is a major
cause of out of hospital cardiac arrest. Among patients
who had been successfully resuscitated after out of hos-
pital cardiac arrest and had no signs of STEMI, immedi-
ate angiography was not found to be better than a
strategy of delayed angiography with respect to overall
survival at 90 days.
Answer: B
Panchal AR, Bartos JA, Cabanas JG et al. Part 3: Adult
basic and advanced cardiac life support: 2020 American
Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care.
Circulation. 2020; 142 (suppl 2): S366–S468.
Yannapoulos D, Bartos JA, Aufderheide TP et al. The
evolving role of the cardiac catherization laboratory in the
management of patients with out of hospital cardiac
arrest: a scientific statement from the American Heart
Association. Circulation. 2019; 139 (12): e530–e552.
Lemkes JS, Janssens GN, van der Hoeven NW et al.
Coronary angiography after cardiac arrest without
ST-Segment elevation. April 11, 2019. N Engl J Med.
2019; 380: 1397–1407. DOI: https://doi.org/10.1056/
NEJMoa1816897
7 A 35-year-old, 26 week pregnant woman has cardiac
arrest with CPR ongoing in the ED. CPR has been
ongoing for 5 minutes. Which of the following has been
shown to provide greatest benefit for achieving ROSC?
A Corticosteroids.
B Targeted temperature management.
C Left lateral uterine displacement.
D Fetal monitoring.
E C-section.
In conditions of cardiac arrest after pregnancy, rapid
delivery of the fetus, typically by C-section, termed peri-
mortem cesarean delivery (PMCD), has been shown to
be associated with improved outcomes when CPR does
not achieve ROSC. However, the decision must be made
quickly as a review article states that if done within
10 minutes of arrest, it was associated with better mater-
nal outcomes. It was also thought that it was beneficial to
14 Surgical Critical Care and Emergency Surgery

the mother in 31% of cases and was not harmful in any was hypothermic or alkalotic, these conditions would
case. The review of the cases resulted in only 94 cases also shift it toward the left.
supporting that PMCD is rare. Corticosteroids have
shown no benefit and targeted temperature manage- 100
ment may be used after achievement of ROSC (choices A
and B).The left lateral uterine displacement alleviates
aortocaval compression in patients with hypotension, 80

Oxygen saturation of hemoglobin (percent)

Left-shifted
but delivery achieves this much more effectively (choice
C). Fetal monitoring during maternal CPR is a distrac-
tion and may hinder care (choice D). 60
Right-shifted
Answer: E

Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and 40

perimortem caesarean delivery: evidence or expert
based? Resuscitation. 2012; 83 (10): 1191–1200.
Panchal AR, Bartos JA, Cabanas JG et al. Part 3: Adult 20
basic and advanced cardiac life support: 2020 American
Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care. 0
Circulation. 2020; 142 (suppl 2): S366–S468. 0 20 40 60 80 100
Partial pressure of oxygen (mmHg)
8 Which of the following scenarios causes a shift of the
oxygen dissociation curve to the left? Answer: A
A A patient found unconscious in a basement apart- Woodson, RD. Physiologic significance of oxygen dissocia-
ment with malfunctioning heater. tion curve shifts. Crit Care Med. 1979; 7 (9): 368–373.
B Patient with pneumonia and fever of 102°C.
C Patient with lactic acidosis from mesenteric 9 You are caring for a patient in the SICU, currently
ischemia. intubated after undergoing left upper lobectomy for
D Patient with depressed mental status taking slow, tumor. Patient’s current hemoglobin is 10 g/dL, oxygen
shallow breaths. saturation 95%, and PaO2 of 92 mmHg. What is the
E Patient returning from climbing Mt Everest where expected oxygen content (CaO2)?
he had to stop and be treated for hypoxia after leav- A 0.9 mL/dL
ing base camp. B 9 mL/dL
C 13 mL/dL
Everest where he had to stop and be treated for hypoxia D 21 mL/dL
after leaving base camp. The oxygen–hemoglobin disso- E 140 mL/dL
ciation curve is sigmoidal in shape based on allosteric
interactions of each globin monomer binding oxygen. A Blood oxygen content is based on the following formula
shift to the right indicates decreased affinity favoring influenced by oxygen saturation, partial pressure of arte-
unloading of oxygen while a shift to the left achieves the rial oxygen, and patient’s hemoglobin:
opposite effect. The strength by which oxygen binds to
CaO2 1.34 Hb SaO2 0.003 PaO2
hemoglobin is affected by several factors and can be rep-
resented as a shift to the left or right in the oxygen dis- 1.34 10 0.95 0.003 92
sociation curve. A rightward shift of the curve indicates 12.73 0.28
that hemoglobin has a decreased affinity for oxygen,
13.01 or 13 mL / dL
thus, oxygen actively unloads. A shift to the left indicates
increased hemoglobin affinity for oxygen and an The single biggest factor for oxygen content is hemo-
increased reluctance to release oxygen. Several physio- globin. Doubling of hemoglobin would double the oxy-
logic factors are responsible for shifting the curve left or gen content. Increasing the partial pressure of oxygen
right, such as pH, carbon dioxide (CO2), temperature, from 60 mmHg to 100 would increase saturation from
and 2,3-Disphosphoglycerate. Carbon monoxide expo- 90 to 100% and would not be a large change in content.
sure, as can be seen in enclosed spaces with a malfunc- The doubling of partial pressure of oxygen from
tioning heater, can result in a leftward shift. If the patient 60 mmHg to 120 mmHg would still only increase the

content by 10% as the dissolved amount of oxygen in
plasma is negated by the factor of 0.003. The constant
of 1.34 is the amount of oxygen that one gram of hemo-
globin carries at 1 atmosphere of pressure.
Answer: C
Crocetti J, Diaz-Abad M, Krachman SL. Oxygen content,
delivery, and uptake. In GJ Criner, RE Barnette, GE
D’Alonzo (Eds), Critical Care Study Guide. New York:
Springer, 2010.
10 Changes in which of the following components is the
most influential in increasing oxygen delivery?
A Cardiac output.
B Hemoglobin level.
C Oxygen saturation.
D Oxygen dissolved in blood.
E Systemic vascular resistance.
As described in the question above, oxygen content is
influenced by hemoglobin, oxygen saturation, and par-
tial pressure of arterial oxygen. Of these, hemoglobin
level, which has the greatest impact on oxygen content
through binding, has the greatest impact on oxygen
available to deliver to tissues. Arterial oxygen saturation
and cardiac output are additional important factors in
ensuring adequate oxygen delivery. Increased cardiac
output as a compensatory mechanism can carry more
oxygenated blood for delivery. Improved oxygen satura-
tions ensure appropriate oxygen availability for hemo-
globin binding. Changes in vascular resistance can
influence oxygen diffusion. The least influential of the
above choices given, the minimal contribution it makes
to available oxygen, is partial pressure of arterial oxygen
i.e. dissolved oxygen.
Answer: B
Marino P. The ICU Book, 4th edn. Philadelphia: Lippincott
Williams & Wilkins, 2007.
11 You are called to the PACU to evaluate a 64-year-old
man with a history of metastatic lung cancer now s/p
video-assisted thoracoscopic resection of the left
upper lobe. His heart rate is 110 beats/min, blood
pressure 70/42 mm Hg. He appears tachypneic. On
examination, he is cool and clammy, with evidence
of peripheral cyanosis and prominent jugular venous
distension. Anesthesia has successfully placed an
arterial line and initiated several fluid boluses while
awaiting your arrival; however, there has been no
significant improvement in his hemodynamics. You
note that his systolic blood pressure on the arterial
line appears to decrease by at least 10 mmHg during
respiration. While you prepare the appropriate
Cardiopulmonary Resuscitation, Oxygen Delivery and Shock 15
intervention, what would be the best next step to help
confirm the likely diagnosis?
A Chest X-ray
B CT angiogram
C CBC
D EKG
E Transthoracic echocardiogram
This patient is exhibiting signs of cardiac tamponade,
with evidence of pulsus paradoxus, jugular venous dis-
tension, and hypotension. The primary tool for diagnosis
of cardiac tamponade is Doppler echocardiography,
which in the presence of tamponade typically shows a
circumferential pericardial fluid layer and compressed
chambers with high ventricular ejection fractions. On
inspiration, both the ventricular and atrial septa move
leftward and reverse on expiration, due to the fixed peri-
cardial volume. Right ventricular collapse is typically less
sensitive but more specific for tamponade. The inferior
vena cava is typically dilated with minimal respiratory
variation. CT angiogram may demonstrate pericardial
effusion, distension of the superior and inferior vena
cavae, and reflux of contrast material into the azygos
vein and inferior vena cava. However, these represent
static images rather than the dynamic information pre-
sented by echocardiography. Chest x-ray may demon-
strate an enlarged cardiac silhouette but is particularly
unreliable in early/acute tamponade (choice A).
Additionally, obtaining a CT scan is typically not porta-
ble, requiring transporting a hemodynamically unstable
patient to obtain the study (choice B). A CBC would be of
little use to obtaining this diagnosis (choice C). EKG may
show evidence of pericarditis or electrical alternans but
is unreliable in the diagnosis of tamponade (choice D).
Answer: E
Spodick DH. Acute cardiac tamponade. N Engl J Med.
2003; 349 (7): 684–90. doi: https://doi.org/10.1056/
NEJMra022643. PMID: 12917306.
12 A 27-year-old man presents after jumping from a
diving board and striking the bottom of a pool with
his upper body. On presentation, he has no sensation
or motor strength of his lower extremities. On exami-
nation, he appears flaccid and you cannot elicit spinal
reflexes. His heart rate is 54 beats/min, blood pressure
90/54, and respiratory rate 18. Despite appropriate
fluid resuscitation, he remains hypotensive, though
you identify no evidence of ongoing hemorrhage. What
type of shock does this likely represent?
A Obstructive
B Distributive
C Cardiogenic
D Hypovolemic
E Anaphylactic
16 Surgical Critical Care and Emergency Surgery
This patient demonstrates bradycardia, hypotension,
and neurologic deficits in the setting of possible cervical
or high thoracic spine trauma, suggesting he may have a
component of neurogenic shock. This shock is a result of
spinal cord injury with sudden loss of sympathetic tone
with preserved parasympathetic activity and autonomic
instability, leading to bradycardia and hypotension.
These changes are typically seen with an injury to the
spinal cord above T6. Disruption of the sympathetic divi-
sion of the autonomic nervous system affects three areas
of the cardiovascular system: coronary blood flow, car-
diac contractility, and heart rate. There is systemic hypo-
tension due to a decrease in sympathetic fiber-mediated
arterial and venous vascular resistance, along with
venous pooling and loss of preload, with or without
bradycardia. The bradycardia is often exacerbated by
suctioning, defecation, turning, and hypoxia. The hypo-
tension places patients at increased risk of secondary
spinal cord ischemia due to impairment of autoregula-
tion. With preserved parasympathetic activity, this trans-
lates clinically into bradycardia (and possibly other
cardiac arrhythmias) in the setting of profound hypoten-
sion. Trauma patients are hypotensive as a result of blood
loss or intravascular hypovolemia but will mount an
appropriate tachycardic response. Blood loss must be
ruled out and treated appropriately before assuming that
hypotension is due solely to spinal cord injury. It is com-
mon to have both blood loss and spinal cord injury.
Initial management is composed of volume resuscitation
to account for the increased intravascular space second-
ary to increased vasodilation, as well as vasopressors for
blood pressure control. In addition to pressor support,
chronotropic and inotropic support may be necessary.
Norepinephrine is started initially but in refractory
cases, epinephrine and vasopressin infusions may be
required. Bradycardia usually responds to atropine and
glycopyrrolate but in severe cases, dopamine infusion is
required. When blood loss is a part of the presentation,
volume resuscitation should be with blood products and
not crystalloids. Spinal shock is often confused with neu-
rogenic shock. Spinal shock, on the other hand, refers to
loss of all sensation below the level of injury and is not
circulatory in nature. Both may, however, coexist in a
patient.
Answer: B
Stein DM, Knight WA. Emergency neurological life
support: traumatic spine injury. Neurocrit Care. 2017; 27
(Suppl 1): 170–180.
Phillips AA, Krassioukov AV. Contemporary cardiovascu-
lar concerns after spinal cord injury: mechanisms,
maladaptations, and management. J Neurotrauma. 2015;
32 (24): 1927–42. doi: https://doi.org/10.1089/
neu.2015.3903. Epub 2015 Sep 1. PMID: 25962761.
13 Shock is defined as:
A Blood pressure less than 90 mm Hg.
B Heart rate greater than 140 beats/min.
C Urine output less than 0.5 ml/kg/hr.
D Inadequate perfusion to meet end organ meta-
bolic needs.
E All of the above.
Shock is defined by some as inadequate perfusion to
meet end organ metabolic needs. Tissue and cellular
hypoxia can be due to inadequate delivery, increased
consumption, inadequate utilization, or a combination
of these states. Although this is often reflected in hemo-
dynamic changes such as hypotension, tachycardia, or
oliguria, these are not sufficient criteria alone to diagno-
sis a patient as being in shock. A patient may present
hypertensive, normotensive, or hypotensive. Conditions
such as neurogenic shock may result in a patient with
bradycardia despite inadequate perfusion. Shock can be
further differentiated into hypovolemic, cardiogenic,
obstructive, or restrictive (vasodilatory/distributive).
Causes of obstructive shock include pulmonary embo-
lism, tension pneumothorax, and pericardial tampon-
ade. Causes of obstructive shock typically lead to
decreased cardiac output and are sometimes included
into the cardiogenic shock category. Identification of
these sub categories of shock is crucial to guiding thera-
peutic intervention.
Cardiogenic shock
Extrinsic (tamponade)
Intrinsic (failure, ischemia)
Hemorrhagic
Distributive
Neurogenic
Answer: D
Kislitsina ON, Rich JD, Wilcox JE et al. Shock - classifica-
tion and pathophysiological principles of therapeutics.
Curr Cardiol Rev. 2019; 15 (2): 102–113. doi: https://doi.
org/10.2174/1573403X15666181212125024. PMID:
30543176; PMCID: PMC6520577.

Vincent JL, De Backer D. Circulatory shock. N Engl J Med.
2013; 369: 1726.
14 A 53-year-old woman with a history of ulcerative
colitis controlled with 50 mg of oral prednisone daily
undergoes a laparoscopic converted to open colec-
tomy. Intra-operatively there are no complications
noted and she receives appropriate fluid resuscita-
tion. However, post-operatively she is noted to be
febrile and hypotensive. This hypotension is refrac-
tory to additional fluid boluses or multiple vaso-
pressors. On physical examination, her abdomen
does not appear distended and she is appropriately
tender. What would be the best next step in manage-
ment of this patient?
A Additional fluid boluses.
B Adding on an additional vasopressor.
C Return to the operating room for exploration.
D Administer stress dose hydrocortisone.
E Begin broad-spectrum antibiotics.
This patient with a history of chronic adrenal suppres-
sion due to daily prednisone use presents with signs and
symptoms consistent with an adrenal crisis. These events
are typically brought on by an inability for the body to
mount an appropriate response to an insult by generat-
ing endogenous cortisol secondary to chronic adrenal
suppression. Unless administered appropriate exoge-
nous glucocorticoids, they may exhibit evidence of hypo-
tension refractory to typical interventions, abdominal
pain, nausea/vomiting, and confusion. Additional fluid
boluses or adding an additional vasopressor would not
address the underlying pathology and has already been
described as unsuccessful in this vignette (choices A, B).
Initiating broad-spectrum antibiotics similarly does not
address the underlying issue and would have no impact
on this patient’s hemodynamics (choice E). Septic shock
would most likely develop later and not immediately.
While a hypotensive patient post-operatively may be due
to blood loss and ultimately require return to the operat-
ing room for exploration, in this case, failure to recog-
nize the underlying adrenal crisis would result in
unnecessary re-exploration (choice C).
Answer: D
Rushworth RL, Torpy DJ, Falhammar H. Adrenal Crisis. N
Engl J Med. 2019; 381 (9): 852–861. doi: https://doi.
org/10.1056/NEJMra1807486. PMID: 31461595.
15 A 71-year-old patient has acute, non-perforated
appendicitis. His BMI is 27 and otherwise healthy.
Intra-operatively you begin with Veress needle
insertion into the abdomen and begin to establish
pneumoperitoneum with high flow rates. Your
Cardiopulmonary Resuscitation, Oxygen Delivery and Shock 17
anesthesiologist immediately notes a marked
decrease in the patient’s end-tidal carbon dioxide
and oxygen saturations as well as new onset tachy-
cardia. You halt insufflation but the patient quickly
becomes hemodynamically unstable. What is your
best step to address the underlying pathology?
A Convert to open.
B Place the patient in steep Trendelenburg and
place a central line for therapeutic intervention.
C Administer fluid bolus.
D Start vasopressors.
E Abort the procedure and transfer the patient to
the ICU.
This patient is demonstrating evidence of possible air
embolism secondary to intravascular insufflation. The
primary goal in this case is to prevent further gas entry
into the venous system and reduce the amount of gas
trapped in the heart. Placing the patient in Trendelenburg
position maximizes blood flow to the brain and theoreti-
cally relieves right-sided heart airlock as well as prevent
gas entry into the pulmonary artery. In a patient who is
hemodynamically unstable secondary to an air embo-
lism, a central line should be placed into the right atrium
and attempts made to withdraw air from the right side of
the heart. Converting to open would not address the
underlying issue (choice A). Initiating fluids or vasopres-
sors would briefly temporize the patient but would not
address the underlying pathology (choices C, D).
Aborting the procedure and taking a hemodynamically
unstable patient to the ICU would not be correct as the
underlying pathology should be addressed prior to leav-
ing the operating room (choice E).
Answer: B
Sandadi S, Johannigman JA, Wong VL et al. Recognition
and management of major vessel injury during laparos-
copy. J Minim Invasive Gynecol. 2010; 17 (6): 692–702.
doi: https://doi.org/10.1016/j.jmig.2010.06.005. Epub
2010 Jul 24. PMID: 20656569.
16 A 32-year-old healthy man was passed out in a
workplace fire but had minimal burns to the right
hand. Given suspected inhalation injury, you take
care to establish a definitive airway and transfer the
patient to the ICU for additional monitoring. The
patient is initially tachycardic and hypertensive but
shortly thereafter develops bradycardia, hypoten-
sion, and cardiac dysrhythmias. On physical exami-
nation, his skin appears flushed with a cherry-red
color. Labwork reveals a marked metabolic acidosis
on arterial blood gas and serum lactate is 9 mmol/L.
His carboxyhemoglobin level is normal. Which of the
18 Surgical Critical Care and Emergency Surgery
following would be most effective in addressing his
underlying pathology?
A Aggressive fluid resuscitation
B Administration of hydroxocobalamin
C Vasopressor support
D Diuresis
E Continue supportive care
This patient is showing evidence of possible cyanide poi-
soning with evidence of cardiovascular instability,
marked metabolic acidosis, and classic “cherry-red” skin
color. Although present in only a minority of patients,
this finding is a result of impaired tissue oxygen utiliza-
tion, resulting in high venous oxyhemoglobin concentra-
tion, and bright red appearance of the blood.
Hydroxocobalamin is a precursor of Vitamin B12 that
directly binds to intra-cellular cyanide, forming cyano-
cobalamin. This molecule is then readily excreted in the
urine. This treatment acts rapidly, does not affect tissue
oxygenation, and is relatively safe, making it a first-line
agent for cyanide poisoning. The other answer questions
do not address what is driving the patient’s underlying
pathology.
Answer: B
Hendry-Hofer TB, Ng PC, Witeof AE et al. A review on
ingested cyanide: risks, clinical presentation, diagnos-
tics, and treatment challenges. J Med Toxicol. 2019; 15:
128.
17 A 37-year-old patient is admitted to the floor after
suffering a femur fracture during a MVC. While he is
stable over the next 24 hours, he shortly thereafter
develops a new petechial rash on the non-dependent
portions of his body, becomes hypotensive, confused,
tachypneic, and is hypoxic on pulse oximetry. A chest
x-ray is obtained but appears normal. A CT angio-
gram of the chest does not demonstrate any evidence
of pulmonary thromboembolism. What would be the
next step in management?
A Supportive care with fluid resuscitation and
oxygenation
B Intravascular tPA lytic therapy
C Broad-spectrum antibiotics
D Vasopressors
E ECMO
This patient is showing evidence of possible fat-embolism
syndrome. This is a rare entity that can be encountered
in patients 24–72 hours after an initial insult (long bone
fracture in this patient). The triad of hypoxemia, neuro-
logic abnormalities, and petechial rash is classic for fat-
embolism syndrome, though non-specific. Fat embolism
can also present with thrombocytopenia and this may
help make a diagnosis. However, it remains a diagnosis of
exclusion, primarily made clinically. Initial assessment is
performed to exclude alternative diagnoses such as pul-
monary embolism. There is no definitive treatment and
therapy is primarily supportive while awaiting resolu-
tion. There is no role for intravascular lytic therapy or
broad-spectrum antibiotics (choices B, C). While vaso-
pressors and invasive ventilator support such as ECMO
may be necessary in patients with refractory shock, they
are not the initial step in management (choices D, E).
Answer: A
Stein PD, Yaekoub AY, Matta F et al. Fat embolism
syndrome. Am J Med Sci. 2008; 336: 472.
18 A 54-year-old patient with a history of diabetes mel-
litus on home metformin presents to your emergency
department with shortness of breath, productive
cough, and fever. On imaging, he is found to have a
right lower lobe opacity consistent with pneumonia.
He is hemodynamically stable but blood work is
noted to have a lactic acidemia of 4 and his glucose
is elevated to 300. His CBC is within normal limits
and an EKG is normal. He is mentating well, making
appropriate urine without evidence of tissue hypop-
erfusion. What best describes the patient’s lactic
academia?
A Type A lactic acidosis
B Type B lactic acidosis
C Septic shock
D Hemorrhagic shock
E Cardiac failure
This patient is showing evidence of lactic acidosis in the
absence of systemic hypoperfusion. Type A lactic acido-
sis is typically related to hypoperfusion secondary to
hypovolemia, cardiac failure, sepsis, or cardiopulmonary
arrest. Type B lactic acidosis occurs when there is no evi-
dence of systemic hypoperfusion and may be related to
impaired cellular metabolism (choice B). Both met-
formin use and diabetes mellitus have been implicated as
associated with Type B lactic acidosis. This patient is
showing no signs of septic, hemorrhagic, or cardiogenic
shock (choices C, D, E).
Answer: B