NORCET 2 - 2021 (shift-1)
Medical & Surgical Nursing
Medium
After a massive blood transfusion, a patient complains of muscle spasms (tetany-like) and rigidity in the extremities. These clinical findings indicate which electrolyte imbalance?
Appeared in: NORCET 2 - 2021 (shift-1)
Explanation
- Stored blood products contain citrate, an anticoagulant that prevents clotting by binding to calcium.
- During a massive transfusion, the large volume of infused citrate binds with the patient's ionized (active) calcium, leading to a rapid decrease in serum calcium levels (hypocalcemia).
- Hypocalcemia increases neuromuscular excitability, causing the characteristic symptoms of tetany, muscle spasms, and rigidity.
- This is a well-documented and anticipated complication of massive transfusion protocols.
Why Other Options Were Wrong
- Option A: Hypercalcemia (high calcium) causes decreased neuromuscular excitability, leading to muscle weakness, fatigue, and diminished reflexes, which is the opposite of the patient's symptoms.
- Option B: While hypokalemia (low potassium) can cause muscle cramps and weakness, it does not typically cause the severe tetany and rigidity described. The primary cause related to citrate is hypocalcemia.
- Option D: Hyperkalemia (high potassium) is a known risk of massive transfusion due to the lysis of old red blood cells in stored blood. However, its classic manifestation is muscle weakness and life-threatening cardiac arrhythmias (peaked T-waves), not tetany.
Related Visual
- Visual 1: Diagram: A visual showing citrate molecules from transfused blood binding to ionized calcium (Ca²⁺) in the bloodstream, making it unavailable for bodily functions.
- Visual 2: ECG Strip: An electrocardiogram demonstrating a prolonged QT interval, a characteristic finding in hypocalcemia.
Clinical Relevance
- Nursing practice connection: Safe nursing care depends on performing Complications of Massive Blood Transfusion in the correct sequence, documenting the action clearly, and monitoring for the expected response.
- Nurses managing a Massive Transfusion Protocol (MTP) must anticipate and monitor for hypocalcemia. It is a common and treatable complication.
- Prompt recognition of perioral tingling, muscle twitching, or spasms allows for early intervention with IV calcium, preventing progression to severe tetany, laryngospasm, or cardiac arrhythmias.
- What if the patient had pre-existing liver disease? The risk of citrate-induced hypocalcemia would be significantly higher because the liver is responsible for metabolizing citrate. With impaired liver function, citrate accumulates, leading to more profound and prolonged hypocalcemia.
How to Approach the Question
- First, identify the key elements in the question: 'massive blood transfusion' and the specific symptoms 'muscle spasms (tetany-like) and rigidity'.
- Recall the composition of stored blood. Remember that it contains anticoagulants, with citrate being the most common.
- Consider the physiological role of citrate. Its function is to bind calcium to prevent clotting.
- Connect the dots: A large volume of citrate (from the transfusion) will bind a large amount of the patient's calcium.
- Relate the resulting electrolyte imbalance (hypocalcemia) to its known clinical manifestations. Low calcium increases neuromuscular excitability, which perfectly matches the symptoms of tetany and spasms.
- Evaluate the other options. Hyperkalemia is also a risk but causes weakness. Hypercalcemia and hypokalemia do not fit the clinical picture as well as hypocalcemia.
Concept Tested & Keywords
- Concept Tested: Complications of Massive Blood Transfusion
- Stem keywords: massive blood transfusion, muscle spasms, tetany, rigidity, electrolyte imbalance
- Lead-in keywords: indicate which
- Clinical cues: The combination of a massive blood transfusion followed by tetany-like symptoms is a classic presentation of acute hypocalcemia.
Question ID
QO-jHSaqgb5PbMw952ov3t
Practise the full NORCET 2 - 2021 (shift-1)
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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