Term 2 Week 6 (w/c 20/2/12)
This week @gasclass is on call for Critical Care.
You have been called to the Emergency Department to see a 32 year old lady who is having difficulty breathing.
What thoughts cross your mind as you walk quickly to the department?
You arrive in the Emergency Department to find a lady complaining of increased shortness of breath and chest tightness. She has previously been admitted to a Critical Care unit at another hospital approximately 4 months ago with an exacerbation of her asthma and improved with medical management. She has used her home nebulisers with no relief of symptoms.
What is your management plan now? What further information would you want?
You assess the patient. She is currently being treated with further nebulised salbutamol and ipratropium. Magnesium infusion has been commenced. When you examine her she has a respiratory rate of 29, SpO2 is 98% on 85% Oxygen via a resevoir mask. Auscultation reveals reduced bilateral air entry with widespread wheeze. Her heart rate is 130bpm and BP 127/82.
CXR is shown below.
Her ABG on 85% O2 are: pH 7.32 pO2 24.5 pCO2 4.5 BXS -5
What are your thoughts now? What are you going to do next ?
She is admitted to an integrated Critical Care Unit. Despite maximal medical management she continues to show no signs of improvement and is now looking tired. Repeat ABG on 85% O2 show: pH 7.20 pCO2 8.0 pO2 29.2 BXS -2.5
A decision is made to intubate and ventilate her.
What is your plan for intubation? What agents will you use? How will you set up the ICU ventilator?
You have successfully intubated the patient and are ventilating her on Pressure Controlled Ventilation (PCV). Her Inspitatory pressure (Pinsp) is 30 and Rate 18 and she is achieving tidal volumes of approximately 350mls the I:E ratio is 1:3
Over the next few hours her ventilation deteriorates and she requires a Pinsp of 40 cmH20 to achieve tidal volumes of 300mls.
What are you going to do now?
The patient continues to deteriorate, she now has ABG on 80% as follows: pH 7.02 pCO2 14.0 pO2 16kPa. She has become cardiovasularly unstable and requires increasing vasopressors. She has multiple arrhythimas as a result of her acidosis.
What are your thoughts about further management? What management options are left?
Case summary will follow.
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