Home > Acute medicine, Anaesthesia, Critical Care, Emergency Medicine > Term 2 Week 6 (w/c 20/2/12)

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?

#gasclass Transcript Term 2 Week 6

Case summary will follow.

@gasclass

There are no trick questions on #gasclass. It is an educational tool only so please feel free to join the conversation. Remember to include the phrase #gasclass in your response. This is referred to as a ‘hashtag’ and you can easily follow the conversation by searching for ‘#gasclass’ in your twitter client. We are really keen on some new contributors and especially welcome Core Trainees and Pre Fellowship STRs. Feel free to pose questions to some of the more senior tweeters!

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  1. Janet Evans
    February 20, 2012 at 7:55 am

    As an ODP on the way to Resus, I’m thinking about initially administering oxygen, putting on full monitoring (if not already done), preparing for intubation, possible causes for the difficulty in breathing, and hoping the anaesthetist gets to resus at the same time as me!

    • February 20, 2012 at 9:28 pm

      To follow the case discussion search for #gasclass on Twitter and see what other people are saying.

  2. Maj
    February 20, 2012 at 2:55 pm

    a) ABC and stabilise as far as possible.
    b) History, history, history. Differential is too wide at this point, have seen this presentation result in diagnosis as varied as simple pneumonia to liver abscesses.

  3. Maj
    February 21, 2012 at 10:35 pm

    Would be tempted to continue medical mx in the hope the spasm will break. It’s certainly not going to improve on on a vent – in fact situation will likely get much worse before better.

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