Shock and Resuscitation (7 to 13 Case studies)
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7)  A 45-year-old man with cirrhosis caused by hepatitis C has been vomiting bright red blood for 1 day. On arrival to the hospital, the patient is confused and unable to provide more information. His family states that he has been vomiting large amounts of bright red blood every 4 hours and has no prior history of GI bleeding. His BP is 76/44 mm Hg, HR is 130 beats per minute, RR is 24 breaths per minute, and oxygen saturation is 98% on room air. His abdomen is soft with no masses. His rectal examination reveals bright red blood. Which type of fluid is most critical in his resuscitation?
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8) A 25-year-old man is brought into the emergency a stab wound to the right lower abdomen. On arrival, the patient has no complaints and wants to leave. His temperature is 98.40F, BP is 130/95 mm Hg, HR is 110 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 98% on room air. He is alert and oriented to person, place, and time. His abdomen is soft and nontender, with normal bowel sounds. He has a 2-cm stab wound with visible subcutaneous fat in his right lower quadrant. You initiate the focused abdominal sonogram for trauma (FAST) examination. Which type of fluid should you start for his initial resuscitation?
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9)  An 18-year-old college student presents with a diffuse rash. She also describes having a headache, fever, and arthralgias for 3 days. On examination, her temperature is 101.2°F, BP is 120/63 mm Hg, HR is 110 beats per minute, RR is 24 breaths per minute, and oxygen saturation is 98% on room air. The patient is alert and oriented to person, place, and time. She has nuchal rigidity and photophobia. Her gums are oozing blood. Her abdomen is soft and nontender and her skin has a diffuse, petechial rash. You diagnose meningococcemia and immediately start ceftriaxone and vancomycin. Her laboratory results reveal a white blood cell count of 13,400/µL, hematocrit 36%, platelets 80,000/ml, PT 60 seconds, international normalized ratio 1.9, and fibrinogen 250 g/L. Which is the most appropriate next step in management?
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10) A 72-year-old man with a history of COPD and hypertension presents with shortness of breath and fever. His medications include albuterol, ipratropium, prednisone and hydrochlorothiazide. His temperature is 102.1°F, BP is 70/40 mm Hg, HR is 110 beats per minute, RR is 24 breaths per minute, and oxygen saturation is 91% on room air. The patient is uncomfortable and mumbling incoherently. On chest examination, there are rales on the left side of his chest. There are no murmurs, rubs, or gallops. His abdomen is soft and nontender. You diagnose septic shock from pneumonia and start IV fluids, broad-spectrum antibiotics, and a dopamine drip. His BP remains at 75/50 mm Hg. What is the next step in management?
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11)  A 66-year-old woman with a history of depression and hypertension was found very ill by her husband and brought to the hospital. Her husband says that she has recently been depressed and expressed thoughts of suicide. She usually takes fluoxetine for depression and atenolol for hypertension. On arrival, the patient is obtunded, but responds to pain and is maintaining her airway. Her temperature is 98.10F, BP is 70/40 mm Hg, HR is 42 beats per minute, RR is 12 breaths per minute, and oxygen saturation is 94% on room air. On examination, her pupils are 3 mm and reactive bilaterally. Lungs are clear to auscultation. Heart is bradycardic, but regular, with no murmurs, rubs, or gallops. Extremities have no edema. An ECG shows first-degree AV block at 42 beats per minute, but no ST/T wave changes. Blood sugar is 112 mg/dL. What is the most specific treatment for this patient's ingestion?
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12)  A 21-year-old man suffers a single gunshot wound to the left chest and is brought in by his friends. He is complaining of chest pain. On examination, his temperature is 99°F, BP is 70/40 mm Hg, HR is 140 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 96% on room air. He has distended neck veins, but his trachea is not deviated. Lungs are clear to auscultation bilaterally. Heart sounds are difficult to appreciate, but you feel a bounding, regular pulse. Abdomen is soft and non-tender. Extremity examination is normal. Two large-bore IV lines are placed and the patient is given 2 L of normal saline. Chest radiograph shows a globular cardiac silhouette, but a normal mediastinum and no pneumothorax. What is the definitive management of this patient?
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13) A 50-year-old man with a history of hypertension presents with severe left-sided chest pain for 1 hour. The pain radiates down his left arm and he feels nauseated. His temperature is 98.3°F, BP is 160/92 mm Hg, HR is 92 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. The physical examination is normal. His ECG shows ST-segment elevations in leads II, Ill, and aVF. You administer aspirin, nitroglycerin, and morphine sulfate and wait for his laboratory results. 10 minutes later the patients BP dropped to 60/30 mm Hg with a HR of 100 beats per minute. What is the most likely cause of his hypotension?
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