Question of the Week # 82

Q82) A 35 y/o woman was admitted for Thrombotic thrombocytopenic purpura and was receiving plasmapheresis. She became agitated one evening and pulled off her right jugular catheter which has been her plasmapheresis access. Arrangements are being made to obtain an alternate access for plasmapheresis. On examination her B.P is 60/32., HR: 120, Tm: 102, RR 24. Physical examination revealed a remnant of jugular catheter that’s still bleeding. You remove the catheter immediately. Chest is clear to auscultation bilaterally. The patient is now crashing and blood pressure is no longer recordable but palpable at 60. Next immediate step in managing this patient is :

A) Pericardiocentesis

B) Start IV fluids

C) Put patient in trendelenberg position

D) Needle thoracentesis

E) Portable chest x-ray

F) 2D echo

12 Responses

  1. I think the answer is b

  2. bbb

  3. d

  4. C

    The most common problem is a drop in blood pressure, which can be experienced as faintness, dizziness, blurred vision, coldness, sweating or abdominal cramps. A drop in blood pressure is remedied by lowering the patient’s head, raising the legs and giving intravenous fluid.

  5. First give the fluids then the position

  6. First the fluids then the positioning

  7. air embolims is most likely since catheter was broken and the site was left open. best mgt is treendelenburg+left lateral decubitus positions and high flow O2 plus minus hyperbaricO2.

  8. dr red please explain why this one is c and not b?

  9. Sudden hypotension and shock with no explainable cause except for the presence of a risk factor for venous air embolism (VAE) point to VAE but there are other possibilities too.- mostly the result of blood or air in the extravascular intrathoracic space. Cardiac tamponade and tension pneumothorax are two other explanations for obstructive cardiogenic shock here. Massive hemothorax from carotid artery rupture or extremely low platelet count in TTP could explain this scenario too.
    Time is of the essence here. I think this question is trying to tell us that and it’s testing our strategy to salvage seconds and provide the most efficient care. The next immediate step should be the easiest, the quickest and the least demanding from a list of beneficial options. Option C, Tredelenburg positioning is simply raising the foot of the bed to increase venous return. Easy and effective and improved venous return will benefit all forms of shock here.
    If intranasal oxygen was in the options, that would be my first choice. In CSS I will start with Oxygen and positioning.
    Then followed by percussion of chest and cardiac auscultation to exclude tension pneumothorax and cardiac tamponade – two very strong other possibilities here, and to exclude hypovolemic shock from intrathoracic third space bleeding.
    Ftesis (Option A). If this exam reveals normal findings, then i would suspect VAE.
    Positioning, intranasal oxygen, and relevant cardiopulmonary exam and rom here, pneumothorax will require Needle thoracocenthesis, Option D.
    Cardiac tamponade will require IV fluids and bed side echo and pericardiocenOption C should not take more than a few seconds.
    Then my next step? after all this would be Option B, IV Fluids. Starting IV fluid in shock may not be as easy and straight forward task and it has the potential of turning into a challenging exercise. But it is definitely indispensable.
    You might be thinking about ER imaging like portable CXR and 2D Echo (Trans-thoracic Doppler Ultrasound). These options would definitely be my next in line in management after IV fluids and/or needle thoracocentesis.

    I agree with Yora. My answer is option C.

    • sorry for the spelling errors. Ftesis (Option A) = Pericardiocentesis,
      ‘Positioning, intranasal oxygen, and relevant cardiopulmonary exam and Option C should not require more than a few seconds.’
      ‘Pneumothorax will require Needle thoracocentesis (Option D)’
      ‘Cardiac tamponade will require IV fluids and bed side echo and pericardiocentesis (Option A)’

  10. C

  11. is the management of different types of shock in ER in the archer videos, need more explanation on this please, thanks

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