6/25 CorePendium Board Review

A 68-year-old male on hemodialysis presents with active bleeding from his AV fistula site shortly after his dialysis session. He is alert but anxious. Bleeding is brisk but not pulsatile.

What is the most appropriate initial intervention?

• Apply a tourniquet proximal to the site

• Hold direct pressure over the bleeding site for 10–15 minutes

• Immediately suture the bleeding point

• Administer protamine sulfate

A 71-year-old woman on dialysis presents with sudden spontaneous bleeding from a known pseudoaneurysm at her AV graft site. EMS reports profuse bleeding. On arrival, she is hypotensive and pale.

What is the most appropriate next step?

• Immediate ultrasound to confirm the pseudoaneurysm

• Apply direct pressure and prepare for emergent surgical consultation

• Administer topical thrombin and observe

• Use cyanoacrylate tissue adhesive

A 63-year-old male with ESRD presents with oozing at his AV graft site. His BP is stable, but he reports using aspirin and apixaban. Bleeding continues despite 15 minutes of direct pressure.

What is the next best step?

• Administer vitamin K

• Place a pressure strap and reattempt compression

• Reverse apixaban with andexanet alfa

• Administer tranexamic acid (TXA) topically on gauze

A dialysis patient with known uremic platelet dysfunction presents with prolonged oozing from the AV fistula access site. He is not anticoagulated. Labs show normal platelets and INR.

What treatment is most appropriate to improve platelet function?

• Cryoprecipitate

• Desmopressin

• Platelet transfusion

• Vitamin K

A 70-year-old dialysis patient presents with bleeding from an AV fistula that was accessed less than 3 weeks after creation. Exam shows shiny, stretched skin and a pulsatile mass.

What is the most likely diagnosis?

• Site infection

• Aneurysm rupture

• Pseudoaneurysm

• Normal post-cannulation swelling

A 72-year-old man with ESRD on thrice-weekly hemodialysis presents 12 hours after his last session with confusion, vomiting, and a witnessed generalized tonic-clonic seizure. He missed his prior dialysis session due to transportation issues. CT head is negative for acute pathology. Which of the following is the most appropriate next step in management?

• Administer hypertonic saline and observe for improvement

• Begin empiric antibiotics and obtain blood cultures

• Administer lorazepam and perform lumbar puncture

• Obtain EEG to assess for non-convulsive status epilepticus

A 67-year-old woman on continuous ambulatory peritoneal dialysis presents with vague abdominal pain, nausea, and turbid effluent. Dialysate WBC count is 80/μL with 60% PMNs. She has no peritoneal dialysate dwelling at time of ED arrival. What is the next best step?

• Discharge with oral antibiotics and follow-up

• Start empiric intraperitoneal antibiotics and send dialysate for cell count

• Instill dialysate, allow 2-hour dwell, and then collect for repeat analysis

• Remove the peritoneal catheter and switch to hemodialysis

A dialysis-dependent patient presents hypotensive, febrile, and obtunded. A tunneled CVC is present in the right internal jugular vein. Peripheral and catheter blood cultures are drawn. The catheter sample returns positive for MRSA at 1 hour; peripheral sample is positive at 3 hours. What is the best next step in management?

• Begin IV vancomycin and continue dialysis through same catheter

• Begin IV ceftriaxone and consult infectious disease

• Start vancomycin, obtain echocardiogram, and plan catheter removal

• Administer vancomycin and cefepime, then recheck blood cultures in 48 hours

A 60-year-old dialysis patient presents with bleeding from an AV graft site after dialysis. Bleeding is brisk and unrelieved with direct pressure. What is the most appropriate next action?

• Apply hemostatic gauze and discharge if bleeding stops

• Apply firm pressure and gallipot dressing, then observe

• Apply tourniquet proximal and distal to bleeding site and consult vascular surgery

• Administer protamine based on estimated heparin use during dialysis

A 58-year-old man with ESRD presents with dyspnea, diffuse ST elevations, and pericardial effusion on POCUS without tamponade physiology. His last dialysis was 4 days ago. Which of the following is the most appropriate treatment?

• Colchicine and NSAIDs

• High-dose corticosteroids

• Emergent pericardiocentesis

• Urgent hemodialysis