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My God someone got Butt hurt over our comments. Is this the kind of person that the Army is putting out? (or was that too personal?) But here is what you asked for reference I'm posting this in hopes that someone can help me find an answer key for the AMLS PRE test You said you asked for a simple yes or no answer but I took it as you were looking for someone who could find you THE answer key to the AMLS pre-test - so I'll answer your question YES indeedee, I sure can find you the answer key to that precious pre-test, as a matter of fact, I just talked to a AMLS instructor and I have the pre-test and the answer key in front of me on my desk. It's might just be the same answer key as the one I found on the internet which you said you already found. So why are you so upset? You did ask for someone to find you the answer key, well I found it, where do you want it?

This fellow seems a little sick. He has septic shock. By definition: SIRS : [2 or more of (i) HR > 90, (ii) RR>20 or pCO2 < 32 mmHg, (iii) T > 38 or < 26, (iv) leukocytosis or leukopenia or bandemia] Sepsis: SIRS + identified source of infection [pneumonia complicated by secondary ? nosocomial influenza, possibly H1N1]. Septic shock: sepsis + lactemia (lactate > 4mM) or hypotension. http://www.mdcalc.com/sirs-sepsis-and-septic-shock-criteria/ He also may not have the best baseline cardiovascular status [prior MI x 2, ? new-onset a.fib], or respiratory status (COPD). So there's a bit of a question as how other comorbidities may be affecting his presentation / clinical course. A couple of things jumping out: * SpO2 85% may not be that terrible for a COPDer. Is he on home O2 at baseline? Can we get a gas? A CO2 and a bicarb will let us see how effective his respiratory compensation is? On the same token: how is work of breathing, subjectively, is he tiring? * His temperature is concerning. Has he been febrile previously? Is he transitioning towards "cold shock/sepsis"? * I'd love to see a CXR -- does it look ARDSy? * Would be nice to have an ECG, BNP and trop, to see if there's any evidence of STEMI / NSTEMI / heart failure. Granted his trop may be high if his ARF has been prolonged? When was his last period of reasonable U/O? Do we know his baseline NYHA? His med list doesn't suggest a CHF hx. * Why is he hypomagnesemic? Is he a drinker? Is this from the lasix? How much was given? * Goals of care? He's younger, one would assume R1/ full code? Are patient and family amenable to ICU admission / ventilator management? * What's our transport time / mode? Are we going ground am for 20 mins? 3 hours? RW/FW? Helipad to rooftop -- or are we shuttling to the airport on both ends for ground transfer? Presumably our receiving center is tertiary care with full ICU capabilities? Looking forward, with influenza dx and rapid decompensation -- ECMO on site? * Level of consciousness? He sounds sick, but at points in the vignette, it seems like he's talking and alert -- could you clarify this? ------------- Moving on to intervention: (1) He needs a lot of fluid. This seems to be a clear septic shock presentation. WBC of 22 doesn't sound like a stress response to an MI. He has two sources of infection. He's tachycardic and hypotensive. We should start with 20 ml / kg, consider whether we can / should get better access --- CVC if skilled personel exist, or a larger IV. (2) We can leave the a.fib alone for now. At 120/min it's unlikely to be the cause of his hemodynamic compromise. Cardioversion while hypoxic, and a high demand state, is likely going to cause more problems than it resolves. Medical therapy with ARF / significant hypotension would be a brave (read: foolish) decision. (3) If we can bring his pressure up, we could reconsider CPAP/BiPAP, and have another go. If he just "failed" because he's anxious, then we may have time to take another stab at it. (4) If his mentation is poor, and fluids haven't brought up his MAP (55 mmHg), then we have to decide between more fluids and initiating levo, or both concurrently. (5) If we're going to intubate this patient, we need to improve baseline hemodynamics first. The decision to intubate is going to be based heavily on anticipated clinical course -- is the patient tiring, are dealing with respiratory failure? Given the length of transport, is there a high risk of airway compromise, probably better pre-empted in the sending facility? Given his CVP is probably very low, putting positive pressure in his chest without addressing volume status / PVR is going to be a bad idea.