A patient arrives in the ER sent directly from his physician's office. He is a 62 Y/O male with a 25 pack year smoking history. His ideal body weight is 182 lbs. He had severe dyspnea and a weak cough effort.
Auscultation reveals course expiratory crackles and inspiratory crackles at the bases, aeration is faint. The patient has JVD and it is noted that he has dependent edema 2+. His respiratory rate is 22 and shallow.
Vital signs are: 167/66, HR 125, Temp. 38.2 C, pulse oximeter = 86% on 2 liters per minute nasal cannula.
The ER doctor is busy in another room with a code blue and you are asked to evaluate the patient and start therapy.
a.CXR 鈥?bilateral cloudy infiltrates with prominent vascularity
b.ABG 鈥?7.33 / 62 / 34, PaO2 鈥?52 torr and SaO2 鈥?83%
c.CBC 鈥?WBC =18,000, H&H = 18/56
d.Electrolytes 鈥?all within normal limits
What would be you first choice of therapy to administer to the patient?
a.Intubate and place on mechanical ventilation
b.Initiate BiPAP
c.Aerosol treatment with albuterol and atrovent
d.Increase oxygen to 3 liters per minute
e.Advair MDI
f.NT suction
g.Lasix
What would be your next choice?
a. Intubate and place on mechanical ventilation
b.Initiate BiPAP
c.Aerosol treatment with albuterol and atrovent
d.Increase oxygen to 3 liters per minute
e.Advair MDI
f.NT suction
g.Lasix
What would be your next recommendation?
a.Intubate and place on mechanical ventilation
b.Initiate BiPAP
c.Aerosol treatment with albuterol and atrovent
d.Increase oxygen to 3 liters per minute
e.Advair MDI
f.NT suction
g.Lasix
What would be the next recommendation?
a.Intubate and place on mechanical ventilation
b.Initiate BiPAP
c.Aerosol treatment with albuterol and atrovent
d.Increase oxygen to 3 liters per minute
e.Advair MDI
f.NT suction
g.Lasix
The patient has received the therapy you have chosen and an ABG 30 minutes later reveals the following information:
pH = 7.30
PaCO2 = 66 torr
HCO3- = 33 mEq/l
PaO2 = 60 torr
SaO2 = 88%
The patient has not been relieved of his dyspnea and the f = 30, respirations are shallow, and breath sounds have only improved slightly.
Based on this information which would you do next?
a.Intubate and place on mechanical ventilation
b.Initiate BiPAP
c.Place on non-rebreather at 15 l/m
d.Give another aerosolized albuterol and atrovent treatment OH I LOVE THESE :) Reminds me of taking board exams. LOL.
1. Aerosol treatment with albuterol and atrovent.
2. Initiate BiPap - bc intubating copd patients is a last resort.
3. Lasix
4. The blood gas is within normal limits for a chronic COPD'r.....which he is because of his CHF and 25 year smoking past. They run with higher CO2s because of their chronic lung disease. BUT because he is still dyspenic and his respirations are now shallow, I would intubate and initiate mechanical ventilation.
Hopefully thats all correct. Ive been wokring in pediatrics for almost 2 years now. My adult skills are rusty :) Too much and deep |
