Respiratory Case Study

Respiratory Case Study

The following case study is of a 37-year old Hipic male weighing 145 lbs and 70 inches tall found unconscious by his girlfriend. According to her, he was unconscious for about 15 hours and she was concerned because he would not wake or respond and was breathing shallow and slow. She then called 9-1-1. The patient entered the ER by emergency vehicle and on my initial assessment, Pt had an altered mental status, was very unresponsive showing symptoms of a possible drug overdose. The girlfriend told the physician the Pt had taken 75 mg of methadone and an unknown amount of Xanex and other amounts of Benzodiazepines. On assessment, the doctor noticed his altered mental status and unconscious status. He had a gag reflex and responded to pain. Pt had a blood pressure of 63/41 and a 02 saturation of 50% on room air and a heart rate of 108. We put the patient on an oxy mask at 14 liters and his saturation improved to 90%. The Physician then administered Narcan which in return raised the respiratory rate. The physician then eventually intubated with Etomidate.

He is then diagnosed with Acute Renal Failure, Acute Lung Injury with possible aspiration, and CHF with Atrial Fib. The patient has had no prior history of a drug overdose. The patient did, however, have a brother that recently committed suicide and was recently released from jail. The patient does drink alcohol and takes multiple street medications and methadone for pain. For this patient with my initial thoughts would be to order an ABG to test for acidosis and see if there is an electrolyte imbalance, then a possible scan of the brain. An EKG test would also be ordered to see how the heart has dealt with the stress. Giving him Narcan would help block the receptor sites to stop the action of the OD. What ended up being ordered is the ABG, a CT of the brain, EKG, NG tube, Catheter, Glasgow Coma Scale, Chest X-ray, and the lab drew blood. The ABG showed severe metabolic and respiratory acidosis, the glucose of 72, potassium of 4. 9, the calcium of 7. 9 chlorides of 105, C02 of 24, creatinine of 2. 6. The EKG showed atrial fibrillation with rapid ventricular response and signs of CHF.

The lab results showed an electrolyte imbalance, sepsis, and no alcohol. The CT scan showed a hypoxemic brain injury and the x-ray showed infiltrates which are assumed to be from aspiration pneumonia. From this, we know that the patient will stay intubated until further improvement of acidosis, help to reduce possible development of ARDS, Sepsis, and until the patient will be able to breathe on his own. The settings on the vent I would have chosen would have been SIMV, Vt of 550-600, a rate of 15, pressure support of 10, Cpap of 5, at a 100% Fi02 with the ABG reading Ph 7. 1, Pco2 58, P02 56, and sating 76%, Hco3 18. 4. The physician ordered a vent setting, SIMV, 100% Fi02, Vt of 550, rate of 12, pressure support of 10, Cpap of 5. The idea behind these settings is to allow the Pt to ventilate and to breathe off the access co2 and to oxygenate the blood. I would like to have seen a rate of 16 to help with the release of co2. 1 hour later the ABG read Ph 7. 13, Pco2 65, P02 66, Hco3 at 15. 6, and sating 85%. The settings for the Pt as far as respiratory seems to be fine for now unless the Pt develops ARDS.

It is more of a metabolic concern at this time now that the Pt is ventilated. Blood gases go as follows: in the ER for an initial assessment on the vent at 2130 a critical of Ph- 7. 11, Pc02- 58, P02- 56 Hc03- 18. 4 and a saturation of 76% on 100% Fio2 while on SIMV with a rate of 12, Vt of 550, pressure support of 10 and Cpap of 5. The Pt at this time has no spontaneous breathing while on the vent. Due to the drug overdose, the Pt is showing both respiratory and metabolic acidosis with Moderate Hypoxemia. A follow-up ABG, 20 minutes later, results in a Ph of 7. 3, Pco2- 47, Po2- 66, Hco3-15. 6 and sating 85% on 100% Fio2. The Pt is now breathing 21 BPM and a Vt of 605 in addition to the vent settings. The results of the latest ABG have shown small improvement, but still critical Ph and moderate hypoxemia. Another follow up ABG at 0100 shows a small improvement on the Ph to 7. 18, the Pco2 became more acidotic moved to 53, the Po2 improved to 77 which shows he is oxygenating better but still hypoxic, his Hco3 acidosis is improving at a change to 19. 8, and sating 91% now. The Pt is now breathing at a rate that has come down to 10 BPM on his own above and beyond the vent. After consulting with the physician we changed Vt to 600 and the pressure support to 20 and Cpap to 15. The Pt continued on these settings till 0415. The physician then made the change to Bi-level with the settings of a rate of 14 pressure support of 25, and an H/L pressure of 35/15. The Pt at this time is pulling a Vt of 745 and a spontaneous rate of 17 and still at 100% Fio2 and sating 92%. This is the point when the Pt makes the turn.

The Bi-level or APRV was the proper setting for this Pt. He continued to improve over the next several days with he peek pressure climbing to 40. The Pt continues these settings and slowly improves and eventually weaned from the ventilator till the Pt no longer needs support. Pt received AP diameter X-ray to confirm tube placement and to see if there were any kind of infiltrates because of possible aspiration and to eliminate possible pneumothorax and pleural effusion. Findings included mild patchy infiltrates in the right upper to middle lobes. The left lower lobe also has some similar findings but less concerning. This may either be due to lung infection or pulmonary edema. The placement of the ET tube was confirmed at 2 cm above the carina. The NG tube was also confirmed to correct placement. The heart silhouette was not enlarged and stable. No pleural effusion was ever confirmed. Pt will be treated for minor Pneumonitis. X-rays continued throughout his stay and infiltrated were slowly diminished and tube placement was confirmed and never changed. The Lab reported sodium at 142 to be within the normal range, potassium 5. also within the normal range. Chloride at 105 also within the normal range, glucose levels at 169 also within the normal range, calcium at 7. 9 is low. The Pt received ionized calcium through his central line. The Hematology reported the WBC at 4. 4 is at the lower spectrum of normal, the RBC at 5. 70 is within the normal limits, and HCT is 51 which are also in the normal spectrum. Blood work came back good. A sputum sample was taken and results were negative for any growth. The Pt is urinating well and the color is yellow/clear with trace amounts of protein.

No PFT’s were performed. Medications the Pt received in the ER: Dextrose 5% delivered intravenous to hydrate Pt, Sodium Bicarbonate was given intravenously because of the severe acidosis, Norepinephrine gave intravenous to raise the BP to a more stable condition, Dopamine also is given for a vast presser, Etomidate was given to sedate the Pt for intubation, Clindamycin is given due to the allergy of Penicillin to help with any anaerobic infection, Doripenem and Vancomycin other antibiotics, Propofol to keep Pt sedated during his intubation. Medications given while in the ICU: Clopidogrel (Plavix) given to prevent clots, Symbicort gave to help prevent bronchospasm and improve lung function, Digoxin is given for the CHF and slow the heart rate for Atrial Fibrillation, Famotidine to inhibit the production of stomach acid, Lisinopril gave in case of hypertension, Sodium Chloride to treat his hyponatremia, Levophed (Norepinephrine) given when the HR or BP drops, Phenylephrine also a vast presser or to relive nasal decongestion, Pitressin also another vaso presser, Dobutamine to prevent cardiogenic shock, Dopamine for another presser, Fentanyl is given to reduce pain, Haloperidol (Haldol) to help with his mental health, Lorazepam also given to treat his mental health or anxiety, Morphine to treat pain, and Reteplase given for anti-clotting factor.