mobey Posted January 16, 2013 Author Share Posted January 16, 2013 First let me adress the steroids: What are we attempting to achieve with the Dex? The risk is if this is an infection and we give steroids, we could exacurbate it. Do not forget she has been in a hospital for 3 days. For those who are thinking she is fluid overloaded because of crackles: Consider 2 things. 1) Initial air entry sounds 2) Urine output. Are you sure she's overloaded? What else could be causing the crackles? Link to comment Share on other sites More sharing options...
scubanurse Posted January 16, 2013 Share Posted January 16, 2013 Are the crackles hear early or late on the inspiratory phase? Link to comment Share on other sites More sharing options...
Kiwiology Posted January 16, 2013 Share Posted January 16, 2013 I'm fresh out of ideas here people Ugh, are we at the hospital yet? ..... Link to comment Share on other sites More sharing options...
mobey Posted January 16, 2013 Author Share Posted January 16, 2013 Are the crackles hear early or late on the inspiratory phase? Throughout the whole phase Link to comment Share on other sites More sharing options...
mobey Posted January 16, 2013 Author Share Posted January 16, 2013 (edited) Alright let be help ya'll out. She had significant chest trauma 4 days ago. She probably had a pulmonary contusion. She has been splinting her breathing as well due to pain. This all led to a case of SIRS (Systemic inflammatory distress syndrome. http://emedicine.medscape.com/article/168943-overview) She does not meet the criteria perfectly, however she is beta blocked, so she cannot get tachycardic. Knowing that, what do you all think of the chest sounds? How about fluid? Do we give more fluid, or increase the Dopamine to 20? What do you think of her end-tidal? It is still reading 12 There is a very slight sharkfin on the capnography. Some MDI squirts of Salbutamol levels them out nicely. Edited January 16, 2013 by mobey Link to comment Share on other sites More sharing options...
paramatt_ Posted January 17, 2013 Share Posted January 17, 2013 Though I was a bit late to join in, I’m really enjoying the scenario. I was considering two aetiologies, first is the obvious chest infection causing SIRS and ARDS/ALI as described. Second, is the subsequent cardiac failure. Here’s a decent article: http://circ.ahajournals.org/content/116/7/793.full As the crackles are throughout the complete respiratory phase, plus the etc02 and waveform you’re describing, fluid overload seems like a less likely suspect, and more in favor of consolidation As for the steroids, I know they are frowned upon and have been proven to be detrimental early in SIRS, however, the evidence seems to be inconclusive in cases of ARDS. With the amount of pulmonary infiltration present and the long transport time, I would be considering them for this reason. Granted, I would like some additional info if someone with more knowledge and experience than myself has any reason to totally avoid doing so. Link to comment Share on other sites More sharing options...
nancybell Posted January 18, 2013 Share Posted January 18, 2013 Could be a torn diaphragm, or maybe the broken ribs are causing atelectasis. The low urine out put could be from dehydration where she has been in so much pain from the broken ribs. The "bilateral consolidation" could mean pneumonia. Did they even ask why she fell anything not in the normal that might have made her fall? Did they check a baseline glucose? I would really wonder about the urine output and po intake, just because they say the residents eat drink and have good out put doesnt always mean it is a fact, The elevated creatin goes along with acute renal failure and dehydration. Nursing homes are not always places to get reliable information. Link to comment Share on other sites More sharing options...
mobey Posted January 20, 2013 Author Share Posted January 20, 2013 *Bump This one played out? Do we just stick a fork in her? Link to comment Share on other sites More sharing options...
Kiwiology Posted January 20, 2013 Share Posted January 20, 2013 Sorry mate I got really destroyed on valiumz and blacked out for a couple of days ... I think she has some sort of dysfunction of vascular permeability related to the release of inflammatory factors secondary to SIRS / acute infection most likely of respiratory origin but could also be urosepsis. My treatment plan of put on stretcher and take to hospital remains unchanged. Link to comment Share on other sites More sharing options...
mobey Posted January 25, 2013 Author Share Posted January 25, 2013 I'll close this one up. Total Treatment: 7lt Nacl 20mcg/kg Dopamine Intubated with 7.5tube, bagged at 36/min, sedation with Ketamine PEEP at 10cm Ventolin via ET tube Position patient mid fowlers On arrival at ICU 3hrs later, patient went into cardiac arrest (that's right.... all that work and the ICU lets her code). She has ROSC after 2 rounds of Epi, and CPR. Her HR remains at 70bpm, due to the Beta-blocker. 0.1mg I.V. Epi 1:10000 pushed to try raise HR does not work. A Levo infusion is started with the Dopamine. The patient survives the night. Final diagnosis: SIRS leading to ARDS leading to MODS with renal failure, acites, and small insignificant hemothorax. Thx for playing! 1 Link to comment Share on other sites More sharing options...
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