Cardiothoracic Surgery

Cardiothoracic Surgery US Medical PG Question 1: A 27-year-old male arrives in the emergency department with a stab wound over the precordial chest wall. The patient is in distress and is cold, sweaty, and pale. Initial physical examination is significant for muffled heart sounds, distended neck veins, and a 3 cm stab wound near the left sternal border. Breath sounds are present bilaterally without evidence of tracheal deviation. Which of the following additional findings would be expected on further evaluation?

• A. Decrease in central venous pressure by 5 mmHg with inspiration
• B. 15 mmHg decrease in systolic blood pressure with inspiration (Correct Answer)
• C. Decrease in the patient's heart rate by 15 beats per minute with inspiration
• D. Steadily decreasing heart rate to 60 beats per minute
• E. Elevated blood pressure to 170/110

Cardiothoracic Surgery Explanation: ***15 mmHg decrease in systolic blood pressure with inspiration*** - The constellation of muffled heart sounds, distended neck veins, and hypotension (implied by cold, sweaty, and pale appearance) following a precordial stab wound points to **cardiac tamponade**, an acutely life-threatening condition. - A significant drop in systolic blood pressure (>10 mmHg) during inspiration, known as **pulsus paradoxus**, is a classic sign of cardiac tamponade as the increased venous return to the right heart during inspiration bows the interventricular septum, impinging on left ventricular filling. *Decrease in central venous pressure by 5 mmHg with inspiration* - In cardiac tamponade, the **central venous pressure (CVP) is typically elevated** and would not decrease significantly with inspiration due to impaired right ventricular filling. - The elevated CVP contributes to the observed **distended neck veins**. *Decrease in the patient's heart rate by 15 beats per minute with inspiration* - In cardiac tamponade, the body attempts to compensate for reduced cardiac output with **reflex tachycardia**, so a decrease in heart rate is unexpected. - Heart rate usually remains elevated or variable as the heart struggles to maintain perfusion. *Steadily decreasing heart rate to 60 beats per minute* - A steadily decreasing heart rate to 60 bpm (bradycardia) is contrary to the expected physiological response of **tachycardia** in cardiac tamponade as the body compensates for hypoperfusion. - Bradycardia in this context would indicate severe decompensation and imminent cardiac arrest rather than a compensatory mechanism. *Elevated blood pressure to 170/110* - This patient is in **obstructive shock** due to cardiac tamponade; therefore, their blood pressure would be **hypotensive**, not hypertensive. - **Hypotension** is a key component of Beck's triad (muffled heart sounds, distended neck veins, hypotension) which strongly suggests cardiac tamponade.

Cardiothoracic Surgery US Medical PG Question 2: A 64-year-old woman is brought to the emergency department 1 hour after the onset of acute shortness of breath and chest pain. The chest pain is retrosternal in nature and does not radiate. She feels nauseated but has not vomited. She has type 2 diabetes mellitus, hypertension, and chronic kidney disease. Current medications include insulin, aspirin, metoprolol, and hydrochlorothiazide. She is pale and diaphoretic. Her temperature is 37°C (98°F), pulse is 136/min, and blood pressure is 80/60 mm Hg. Examination shows jugular venous distention and absence of a radial pulse during inspiration. Crackles are heard at the lung bases bilaterally. Cardiac examination shows distant heart sounds. Laboratory studies show: Hemoglobin 8.3 g/dL Serum Glucose 313 mg/dL Urea nitrogen 130 mg/dL Creatinine 6.0 mg/dL Which of the following is the most appropriate next step in management?

• A. Furosemide therapy
• B. Pericardiocentesis (Correct Answer)
• C. Aspirin therapy
• D. Hemodialysis
• E. Norepinephrine infusion

Cardiothoracic Surgery Explanation: ***Pericardiocentesis*** * The patient presents with classic signs of **cardiac tamponade**, including **Beck's triad** (hypotension, jugular venous distension, distant heart sounds), **pulsus paradoxus** (absence of radial pulse during inspiration), and acute onset of shortness of breath and chest pain. * Given her history of **chronic kidney disease** and elevated urea/creatinine levels, uremic pericarditis is a likely cause, leading to significant pericardial effusion and tamponade. **Pericardiocentesis** is the definitive treatment to relieve pressure on the heart. *Furosemide therapy* * While **crackles** suggest pulmonary congestion, this patient is severely hypotensive with signs of cardiogenic shock due to tamponade. Administering a diuretic like **furosemide** would further reduce preload, worsening her already compromised cardiac output and hypotension. * The primary issue is extrinsic compression of the heart by pericardial fluid, not left ventricular failure responsive to diuresis. *Aspirin therapy* * The patient's chest pain and other symptoms could potentially point to an acute coronary syndrome, which would warrant **aspirin**. However, her profound hypotension and clear signs of cardiac tamponade (Beck's triad, pulsus paradoxus) make **cardiac tamponade** the more immediate and life-threatening concern. * Addressing the tamponade takes priority as its hemodynamic compromise is more acute and direct. *Hemodialysis* * The patient has severe **acute-on-chronic kidney disease** and likely **uremic pericarditis**. While **hemodialysis** is indicated for uremia, it is not the immediate life-saving intervention for **cardiac tamponade**. * **Pericardiocentesis** is required first to stabilize her hemodynamics; hemodialysis can be performed afterward to address the underlying uremia. *Norepinephrine infusion* * **Norepinephrine** is a powerful vasopressor that would increase systemic vascular resistance and blood pressure. While the patient is hypotensive, the underlying cause is **cardiac tamponade**, which mechanically obstructs cardiac filling and output. * **Vasopressors** alone will not resolve the mechanical obstruction and may even increase myocardial oxygen demand without increasing cardiac output, potentially worsening the situation. The tamponade must be relieved first.

Cardiothoracic Surgery US Medical PG Question 3: A 32-year-old man is brought to the emergency department 10 minutes after he sustained a stab wound to the left chest just below the clavicle. On arrival, he is hypotensive with rapid and shallow breathing and appears anxious and agitated. He is intubated and mechanically ventilated. Infusion of 0.9% saline is begun. Five minutes later, his pulse is 137/min and blood pressure is 84/47 mm Hg. Examination shows a 3-cm single stab wound to the left chest at the 4th intercostal space at the midclavicular line without active external bleeding. Cardiovascular examination shows muffled heart sounds and jugular venous distention. Breath sounds are normal bilaterally. Further evaluation of this patient is most likely to show which of the following findings?

• A. Inward collapse of part of the chest with inspiration
• B. Subcutaneous crepitus on palpation of the chest wall
• C. Cough productive of frank blood
• D. Lateral shift of the trachea toward the right side
• E. A 15 mm Hg decrease in systolic blood pressure during inspiration (Correct Answer)

Cardiothoracic Surgery Explanation: ***A 15 mm Hg decrease in systolic blood pressure during inspiration*** - The patient's presentation with **hypotension**, **tachycardia**, **muffled heart sounds**, and **jugular venous distention** following a chest stab wound is characteristic of **cardiac tamponade**, a component of **Beck's triad**. - **Pulsus paradoxus**, defined as an inspiratory drop in systolic blood pressure greater than 10 mmHg, is a classic finding in cardiac tamponade due to increased right ventricular filling and bowing of the interventricular septum into the left ventricle during inspiration. *Inward collapse of part of the chest with inspiration* - This finding, known as a **flail chest**, occurs when three or more adjacent ribs are fractured in two or more places, leading to a segment of the chest wall paradoxically moving inward with inspiration. - While it indicates significant chest trauma, it doesn't align with the present signs of **cardiac tamponade**, which is primarily a pericardial issue. *Subcutaneous crepitus on palpation of the chest wall* - **Subcutaneous crepitus** suggests the presence of air in the subcutaneous tissues, typically from a **pneumothorax** or **ruptured bronchus**. - Although possible with chest trauma, the patient's normal breath sounds bilaterally and the specific symptoms pointing to cardiac tamponade make this a less likely primary finding compared to pulsus paradoxus. *Cough productive of frank blood* - **Hemoptysis** (coughing up blood) is indicative of airway or lung parenchymal injury, such as a **tracheobronchial tear** or **pulmonary contusion**. - This symptom does not directly explain the classic triad of cardiac tamponade (hypotension, muffled heart sounds, JVD) observed in this patient. *Lateral shift of the trachea toward the right side* - A **tracheal shift** to the contralateral side is a hallmark sign of a **tension pneumothorax**, where air accumulates in the pleural space, compressing the lung and mediastinum. - The patient's breath sounds are described as normal bilaterally, which makes a tension pneumothorax with tracheal deviation highly unlikely in this scenario.

Cardiothoracic Surgery US Medical PG Question 4: A 45-year-old male is brought into the emergency room by emergency medical services due to a stab wound in the chest. The wound is located superior and medial to the left nipple. Upon entry, the patient appears alert and is conversational, but soon becomes confused and loses consciousness. The patient's blood pressure is 80/40 mmHg, pulse 110/min, respirations 26/min, and temperature 97.0 deg F (36.1 deg C). On exam, the patient has distended neck veins with distant heart sounds. What is the next best step to increase this patient's survival?

• A. Heparin
• B. Intravenous fluids
• C. Aspirin
• D. Intravenous colloids
• E. Pericardiocentesis (Correct Answer)

Cardiothoracic Surgery Explanation: ***Pericardiocentesis*** - The patient's presentation with **hypotension**, **tachycardia**, **distended neck veins**, and **distant heart sounds** after a chest stab wound is classic for **cardiac tamponade** (Beck's triad). - **Pericardiocentesis** is the immediate life-saving procedure to drain the pericardial fluid and relieve pressure on the heart, improving cardiac output. - In penetrating trauma, this serves as a **bridge to definitive surgical management** (thoracotomy or sternotomy). *Heparin* - **Heparin** is an anticoagulant and would worsen the situation by increasing bleeding into the pericardial space due to the stab wound. - It is contraindicated in active bleeding and traumatic injury. *Intravenous fluids* - While **IV fluid resuscitation is recommended** in cardiac tamponade to maintain preload and support cardiac output, fluids alone **do not address the underlying mechanical obstruction**. - The primary issue is **extrinsic compression of the heart** requiring drainage, not hypovolemia alone. - Fluids are supportive but not definitive—**pericardiocentesis is the life-saving intervention**. *Aspirin* - **Aspirin** is an antiplatelet agent and would increase the risk of bleeding, exacerbating the patient's condition. - It is used for conditions like myocardial infarction or stroke prevention, not for acute traumatic bleeding. *Intravenous colloids* - Similar to crystalloid fluids, **colloids** may provide temporary hemodynamic support but do not relieve the mechanical compression of the heart. - They are supportive measures that **do not substitute for definitive pericardial drainage**.

Cardiothoracic Surgery US Medical PG Question 5: A 54-year-old man presents to the emergency department complaining of shortness of breath and fatigue for 1 day. He reports feeling increasingly tired. The medical records show a long history of intravenous drug abuse, and a past hospitalization for infective endocarditis 2 years ago. The echocardiography performed at that time showed vegetations on the tricuspid valve. The patient has not regularly attended his follow-up appointments. The visual inspection of the neck shows distension of the neck veins. What finding would you expect to see on this patient’s jugular venous pulse tracing?

• A. Obliterated x descent
• B. Absent a waves
• C. Large a waves
• D. Decreased c waves
• E. Prominent y descent (Correct Answer)

Cardiothoracic Surgery Explanation: ***Prominent y descent*** - A prominent y descent in the **jugular venous pulse (JVP)** tracing is characteristic of **tricuspid regurgitation**, which is highly probable given the patient's history of **intravenous drug abuse** and previous **infective endocarditis** affecting the tricuspid valve. - The **y descent** reflects the rapid emptying of the right atrium into the right ventricle during early diastole; in tricuspid regurgitation, the increased right atrial volume due to regurgitant flow leads to a more rapid and pronounced fall in right atrial pressure once the tricuspid valve opens. *Obliterated x descent* - An obliterated or absent **x descent** is more typically seen in conditions like **cardiac tamponade** or severe **right ventricular failure**, where there's impaired right atrial filling during ventricular systole. - While the patient has heart issues, the clinical picture strongly points to tricuspid regurgitation, which would not typically cause an obliterated x descent. *Absent a waves* - **Absent a waves** in the JVP tracing most commonly suggest **atrial fibrillation**, where there is no organized atrial contraction. - The case description does not provide information to suggest atrial fibrillation as the primary issue. *Large a waves* - **Large a waves** (cannon a waves) are indicative of conditions where there is increased resistance to right atrial emptying during atrial contraction, such as **tricuspid stenosis**, **pulmonary hypertension**, or certain types of **atrial-ventricular dissociation**. - While the history of endocarditis could theoretically lead to tricuspid stenosis, tricuspid regurgitation is a more common sequela in IV drug users and better fits the overall clinical picture, and stenosis would not cause a prominent y descent. *Decreased c waves* - The **c wave** in the JVP is caused by the bulging of the tricuspid valve into the right atrium during early ventricular systole. - A decreased c wave is not a typical finding in the context of tricuspid regurgitation; rather, a more prominent c-v wave is expected due to the regurgitant flow.

Cardiothoracic Surgery US Medical PG Question 6: A 51-year-old man with a recent diagnosis of peptic ulcer disease currently treated with an oral proton pump inhibitor twice daily presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago. On physical exam, you find his abdomen to be mildly distended, diffusely tender to palpation, and positive for rebound tenderness. Given the following options, what is the next best step in patient management?

• A. Serum gastrin level
• B. Urgent CT abdomen and pelvis (Correct Answer)
• C. H. pylori testing
• D. Abdominal radiographs
• E. Upper endoscopy

Cardiothoracic Surgery Explanation: ***Urgent CT abdomen and pelvis*** - The sudden onset of severe abdominal pain, diffuse tenderness, and **rebound tenderness** in a patient with a history of peptic ulcer disease (PUD) suggests a **perforated ulcer**, which is a surgical emergency. - A CT scan is the **most sensitive imaging modality** for detecting **free air** (pneumoperitoneum) and can confirm the diagnosis with >95% sensitivity, helping to localize the perforation and identify complications such as abscess formation. - CT also helps evaluate alternative diagnoses in the acute abdomen and provides detailed anatomic information for surgical planning. *Serum gastrin level* - This test is primarily used in the diagnosis of **Zollinger-Ellison syndrome**, a rare condition characterized by gastrinomas leading to severe, refractory PUD. - It is not indicated in an acute emergency setting with signs of perforation, as it would delay critical diagnostic imaging and management. *H. pylori testing* - **_H. pylori_ infection** is a common cause of PUD, but testing for it is part of routine initial management or follow-up for chronic disease. - Testing would not address the immediate life-threatening complication of suspected perforation and would delay definitive diagnosis. *Abdominal radiographs* - An upright chest X-ray or abdominal radiograph can detect **free air under the diaphragm** in cases of perforation and is a reasonable initial imaging test. - However, plain radiographs have lower sensitivity (75-80%) compared to CT scan and may miss smaller perforations or provide insufficient information about the location and extent of injury. - In modern practice with readily available CT, cross-sectional imaging is preferred for its superior diagnostic accuracy in evaluating the acute abdomen. *Upper endoscopy* - **Upper endoscopy** is a valuable diagnostic and therapeutic tool for stable PUD but is **absolutely contraindicated** in cases of suspected or confirmed hollow viscus perforation. - Introducing an endoscope with air insufflation could worsen the perforation and lead to further contamination of the peritoneal cavity, increasing morbidity and mortality.

Cardiothoracic Surgery US Medical PG Question 7: A 50-year-old male presents to the emergency with abdominal pain. He reports he has had abdominal pain associated with meals for several months and has been taking over the counter antacids as needed, but experienced significant worsening pain one hour ago in the epigastric region. The patient reports the pain radiating to his shoulders. Vital signs are T 38, HR 120, BP 100/60, RR 18, SpO2 98%. Physical exam reveals diffuse abdominal rigidity with rebound tenderness. Auscultation reveals hypoactive bowel sounds. Which of the following is the next best step in management?

• A. Admission and observation
• B. Chest radiograph
• C. 12 lead electrocardiogram
• D. Abdominal CT scan (Correct Answer)
• E. Abdominal ultrasound

Cardiothoracic Surgery Explanation: ***Abdominal CT scan*** - This patient presents with classic signs of a **perforated peptic ulcer**: sudden severe epigastric pain radiating to the shoulders (diaphragmatic irritation), fever, tachycardia, hypotension, and peritoneal signs (rigid abdomen with rebound tenderness). - While the patient shows signs of **early shock** (BP 100/60, HR 120), he is **conscious and maintaining adequate oxygenation** (SpO2 98%), making him stable enough for rapid CT imaging. - **Abdominal CT scan** is the **most sensitive and specific** test for detecting free air, identifying the location of perforation, and assessing for complications (abscess, contained perforation). - CT provides **critical surgical planning information** about the extent and location of perforation, which can guide the surgical approach. - This should be followed by **immediate surgical consultation** and preparation for emergency laparotomy. *Chest radiograph* - While an **upright chest X-ray** can detect free air under the diaphragm (pneumoperitoneum), it has **lower sensitivity** (70-80%) compared to CT scan (>95%). - In a patient who is stable enough for imaging, **CT is preferred** as it provides more information for surgical planning. - Chest X-ray would be the appropriate choice only if **CT is unavailable** or if the patient is **too unstable** to be transported to the CT scanner. *Admission and observation* - This patient has **acute peritonitis** from a likely perforated viscus, which is a **surgical emergency** requiring operative intervention. - Observation would be inappropriate and dangerous, leading to **septic shock**, **multi-organ failure**, and death. *12 lead electrocardiogram* - While epigastric pain can sometimes be cardiac in origin, the **peritoneal signs** (rigid abdomen, rebound tenderness, hypoactive bowel sounds) clearly indicate an **intra-abdominal pathology**. - The pain radiation to **both shoulders** (Kehr's sign) suggests diaphragmatic irritation from intraperitoneal air or fluid, not cardiac ischemia. *Abdominal ultrasound* - Ultrasound is useful for evaluating **solid organ injury**, **free fluid**, and conditions like **cholecystitis** or **appendicitis**. - However, it is **poor at detecting free air** due to bowel gas artifact and has limited sensitivity for perforated viscus. - It would not provide adequate information for this surgical emergency.

Cardiothoracic Surgery US Medical PG Question 8: Three days after undergoing an open cholecystectomy, a 73-year-old man has fever and abdominal pain. He has hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and benign prostatic hyperplasia. He had smoked one pack of cigarettes daily for 40 years but quit 1 year ago. He does not drink alcohol. Prior to admission to the hospital, his medications included lisinopril, metformin, ipratropium, and tamsulosin. He appears acutely ill and lethargic. His temperature is 39.5°C (103.1°F), pulse is 108/min, respirations are 18/min, and blood pressure is 110/84 mm Hg. He is oriented only to person. Examination shows a 10-cm subcostal incision that appears dry and non-erythematous. Scattered expiratory wheezing is heard throughout both lung fields. His abdomen is distended with tenderness to palpation over the lower quadrants. Laboratory studies show: Hemoglobin 10.1 g/dl Leukocyte count 19,000/mm3 Serum Glucose 180 mg/dl Urea Nitrogen 25 mg/dl Creatinine 1.2 mg/dl Lactic acid 2.5 mEq/L (N = 0.5 - 2.2 mEq/L) Urine Protein 1+ RBC 1–2/hpf WBC 32–38/hpf Which of the following is the most likely underlying mechanism of this patient's current condition?

• A. Wound contamination
• B. Peritoneal inflammation
• C. Impaired alveolar ventilation
• D. Intraabdominal abscess formation (Correct Answer)
• E. Bladder outlet obstruction

Cardiothoracic Surgery Explanation: ***Intraabdominal abscess formation*** - The patient presents with **fever**, **leukocytosis**, **abdominal pain** and **distension** three days post-cholecystectomy. These symptoms, coupled with signs of systemic illness (lethargy, altered mental status, tachycardia, elevated lactic acid), are highly suggestive of an **intraabdominal infection** such as an abscess. - The surgical site incision appears dry and non-erythematous, making a superficial wound infection less likely to explain the systemic symptoms and deep abdominal pain. *Wound contamination* - While wound contamination can cause infection, the incision site is described as **dry and non-erythematous**, suggesting that a superficial surgical site infection is not the primary cause of the patient's systemic illness and deep abdominal pain. - A simple wound infection generally would not lead to such significant systemic symptoms, including **lethargy** and **altered mental status**, within three days post-surgery, especially without local signs of inflammation. *Peritoneal inflammation* - Peritoneal inflammation (peritonitis) is a consequence of an intraabdominal process like an abscess or anastomotic leak, rather than the primary underlying mechanism itself. - The symptoms of **localized tenderness** and **distension** are more indicative of a contained process like an abscess rather than diffuse peritoneal inflammation as the initial cause. *Impaired alveolar ventilation* - While the patient has COPD and scattered expiratory wheezing, suggesting some degree of respiratory compromise, **impaired alveolar ventilation** alone does not explain the fever, elevated leukocyte count, abdominal pain, and an elevated lactic acid (though respiratory distress can contribute to lactic acidemia, an infection is a more direct cause here). - Post-operative pulmonary complications are common, but the abdominal findings and systemic signs of infection point away from a purely respiratory origin for this acute deterioration. *Bladder outlet obstruction* - The patient has BPH and is on tamsulosin, but his current symptoms of fever, leukocytosis, abdominal pain, and elevated lactic acid are not typical for **bladder outlet obstruction**. - Although the urine analysis shows pyuria (WBC 32-38/hpf), which could suggest a urinary tract infection (UTI), a UTI alone is less likely to cause this degree of systemic illness with **significant abdominal distension** and **tenderness** in the lower quadrants shortly after abdominal surgery; it's more probable that the pyuria is a secondary finding or contributing factor in a patient with a more severe intraabdominal process.

Cardiothoracic Surgery US Medical PG Question 9: A 79-year-old man is admitted to the intensive care unit for hospital acquired pneumonia, a COPD flare, and acute heart failure requiring intubation and mechanical ventilation. On his first night in the intensive care unit, his temperature is 99.7°F (37.6°C), blood pressure is 107/58 mm Hg, and pulse is 150/min which is a sudden change from his previous vitals. Physical exam is notable for jugular venous distension and a rapid heart rate. The ventilator is checked and is functioning normally. Which of the following is the best next step in management for the most likely diagnosis?

• A. Tube thoracostomy
• B. FAST exam
• C. Needle thoracostomy (Correct Answer)
• D. Chest radiograph
• E. Thoracotomy

Cardiothoracic Surgery Explanation: ***Needle thoracostomy*** - The patient's sudden deterioration with **tachycardia**, **hypotension**, and **jugular venous distension** (JVD) in the setting of positive pressure ventilation strongly suggests a **tension pneumothorax**. - **Needle decompression** is the immediate life-saving intervention for suspected tension pneumothorax, as delaying treatment for diagnostic imaging could be fatal. *Tube thoracostomy* - While a **tube thoracostomy** (chest tube insertion) is the definitive treatment for pneumothorax, it requires more time and resources than needle decompression. - In a true emergency with signs of tension, needle decompression should be performed first to stabilize the patient, followed by a chest tube. *FAST exam* - A **Focused Assessment with Sonography for Trauma (FAST) exam** is primarily used to detect free fluid (usually blood) in the abdomen or pericardium in trauma patients. - While it can sometimes identify pneumothorax, it is not the fastest or most direct intervention for a suspected tension pneumothorax causing hemodynamic instability. *Chest radiograph* - A **chest radiograph (CXR)** is the standard diagnostic tool for pneumothorax, but obtaining and interpreting it would delay urgent intervention in a hemodynamically unstable patient with suspected tension pneumothorax. - The diagnosis of tension pneumothorax is primarily clinical; treatment should not wait for imaging. *Thoracotomy* - A **thoracotomy** is a major surgical procedure involving opening the chest, typically reserved for severe trauma, massive hemorrhage, or complex thoracic issues. - It is an overly aggressive and inappropriate initial intervention for a suspected tension pneumothorax.

Cardiothoracic Surgery US Medical PG Question 10: An 18-year-old man presents to a rural emergency department after being stabbed multiple times. The patient's past medical history is notable for obesity, diabetes, chronic upper respiratory infections, a 10 pack-year smoking history, and heart failure. He is protecting his airway and he is oxygenating and ventilating well. His temperature is 97.6°F (36.4°C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 24/min, and oxygen saturation is 98% on room air. The patient is started on whole blood and the surgeon on call is contacted to take the patient to the operating room. During the secondary survey, the patient complains of shortness of breath. His blood pressure is 54/14 mmHg, pulse is 200/min, respirations are 24/min, and oxygen saturation is 90% on room air. Physical exam is notable for bilateral wheezing on lung exam. The patient goes into cardiac arrest and after 30 minutes, attempts at resuscitation are terminated. Which of the following is associated with this patient's decompensation during resuscitation?

• A. COPD
• B. Congenital long QT syndrome
• C. Heart failure
• D. IgA deficiency
• E. Persistent intraabdominal bleeding (Correct Answer)

Cardiothoracic Surgery Explanation: ***Persistent intraabdominal bleeding*** - The patient's initial presentation with **uncontrolled hemorrhage due to multiple stab wounds** is the most likely cause of his subsequent decompensation and cardiac arrest. Despite transfusion, persistent bleeding would lead to ongoing **hypovolemic shock**, explaining the worsening hypotension and tachycardia. - The patient's complaint of shortness of breath and wheezing could be a **reaction to hypovolemic shock** or a **transient pulmonary response** related to the ongoing volume loss and metabolic state, rather than a primary respiratory obstructive process. *COPD* - While the patient has a smoking history, his age (18 years old) makes significant **COPD** unlikely to be established enough to cause such a rapid and severe decompensation. - The **wheezing** could be a non-specific response to shock or hypoperfusion, not necessarily indicative of COPD exacerbation in this acute setting. *Congenital long QT syndrome* - This condition is a **cardiac electrical disorder** predisposing to arrhythmias, but it is not directly linked to the traumatic injury or the progressive hypovolemic shock in this clinical scenario. - There is no specific information in the vignette to suggest an **arrhythmia originating from a prolonged QT interval** as the primary cause of his cardiac arrest. *Heart failure* - Although the patient has a history of heart failure, his primary and overwhelming problem is **acute hemorrhagic shock** from the stab wounds. The dramatic drop in blood pressure and rise in heart rate point to volume loss, not primarily cardiogenic shock exacerbation. - While heart failure can complicate resuscitation, it is not the **direct cause of decompensation** in the face of active, life-threatening hemorrhage. *IgA deficiency* - **IgA deficiency** is an immunodeficiency associated with recurrent infections, but it has no direct pathophysiological link to acute traumatic hemorrhage or the rapid cardiovascular collapse experienced by this patient. - It would not explain the sudden severe signs of **hypovolemic shock** or cardiac arrest in this context.

Cardiothoracic Surgery Flashcard 1 of 7

Question: Herniated contents may be at risk for _____, which is characterized by ischemia and necrosis

Answer: strangulation

Cardiothoracic Surgery Flashcard 2 of 7

Question: A _____ is indicated when an emergency airway is required or orotracheal / nasotracheal intubation is unsuccessful / contraindicated

Answer: cricothyrotomy

Cardiothoracic Surgery Flashcard 3 of 7

Question: A _____ presents with a "popping/snap" sound during sexual intercourse; resulting in penile pain, swelling, and ecchymosis

Answer: penile fracture

Cardiothoracic Surgery Flashcard 4 of 7

Question: Bladder irrigation is used for patients with hematuria to prevent the formation of _____

Answer: blood clots

Cardiothoracic Surgery Flashcard 5 of 7

Question: Vocal cord nodules are due to excessive use of vocal cords and are usually _____ (uni- or bilateral)

Answer: bilateral

Cardiothoracic Surgery Flashcard 6 of 7

Question: Commotio cordis is ventricular fibrillation caused by _____

Answer: blunt cardiac injury

Cardiothoracic Surgery Flashcard 7 of 7

Question: Treatment for aortic stenosis is _____ after the onset of complications

Answer: valve replacement