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DartmouthDave

Influenza & Bubbling Chest Tubes

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Hello,

You are part of a ground critical care transport team and you have been dispatched to transfer an influenza patient from a community hospital ICU to the local university hospital. The transport time to the university hospital is 90 minutes.

The patient is a 52 year-old women who present to the ED three days ago with SOB, confusion, hypotension, and respiratory failure.

She was intubated, started on antibiotics, given IV fluids, and admitted to the ICU. Her condition has decompensate further and she has been started on Levophed to support her BP. In addition, she has been difficult to ventilate and has had two chest tubes inserted for a left-side pneumothorax.

You arrive and you find the patient sedated (Propofol + Versed+ Fentanyl gtts) and paralyzed (Nimbex). Levophed is infusing as well. Two chest tubes are bubbling vigorously on the left side.

VS are troubling (HR110 BP 90/40 SpO2 88% Temp 39). Lastly, your patient is looking gray with mottled feet.

Cheers

David

Edited by DartmouthDave

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Since no one else has participated, I guess I will start off. What is the pt's history? What antibiotics is she on and why is she on them if she has influenza? How long has the vigorous bubbling gone on and what happens if we clamp the chest tubes at the skin? Bad things are going on so let's get a chest xray if there isn't a current one.

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Chest x-ray

Lung sounds

Current chem-7

Current CBC

Current ABG

Initial chem-7, CBC, and ABG

How much fluid did she initially recieve, and how much was she given over the last 3 days?

What is the levophed running at, for how long, and has the rate had to be adjusted?

When and why were the chest tubes inserted (symptomatic or did they find the pneumo on x-ray?

What are the vent settings, and have they been adjusted?

What are the drip rates for her sedatives?

Any urine output? If so, how much per day since admission?

What type of venous access is there?

Home medications?

Medical history?

There are things that need to be done and/or changed, but I'd like that info first.

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Chest x-ray

Lung sounds

Current chem-7

Current CBC

Current ABG

Initial chem-7, CBC, and ABG

How much fluid did she initially recieve, and how much was she given over the last 3 days?

What is the levophed running at, for how long, and has the rate had to be adjusted?

When and why were the chest tubes inserted (symptomatic or did they find the pneumo on x-ray?

What are the vent settings, and have they been adjusted?

What are the drip rates for her sedatives?

Any urine output? If so, how much per day since admission?

What type of venous access is there?

Home medications?

Medical history?

There are things that need to be done and/or changed, but I'd like that info first.

Looks like a great starting point to me. As soon as Dave returns we should be off to the races.

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Hello,

Sorry for the slow reply. I upgraded my computer at home and I can not figure out how to turn off the 'ad blockers' software and I can not login to EMT City. I will get my IT department (brother-in-law) to fix things for me.

The chest tubes were put in because the patient developed a tension pneumothorax after a couple attempts at a central line. The patient coded and a spinal needle was used to decompress her (that all they could find in a rush) There is a small red spot where the needle was inserted.

Her CXR is white out with a small effusion on the right side. The chest tubes are in good position on the left.

She is positive 6000cc and her urine output has been falling.

K 5.2

Na 145

Hgb 80

Lact 9.0

Cr 200

Urea 12

INR 1.5

PTT 55

She has a right femoral central line and IV x2. She was a right radial arterial line with a good waveform.

She is on AC 25/550/1.0/+22 ABG (7.40/60/45/-11/9) with a PIP of 36

She is on Levophed at .5mcg/kg/min (80kg so 40mcg/min)

Propofol 150mg/hr + Fentanyl 150mcg/hr + Versed 5mg/hr. Her BIS is 35 so she is deeply sedated. The Nimbex is a 2mcg/kg/min (TOF 0/4).

Otherwise, she is a healthy 52 year-old women who is a little overweight who walked in very ill.

Cheers

Edited by DartmouthDave

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Holy chemistry set Batman! First, let's cut back on a bunch of these meds. There is no need for so many and they are just working against each other. I would get rid of the Fentanyl and Versed drips. That alone may or may not help the pressure. Try to titrate down the propofol. Can you confirm some labs? I question the hgb, Cr, BUN (maybe you are using different units than I am used to). Are we able to get a CT angio of her chest? Any concerns for pathology elsewhere (ie abd and pelvis)? The ABG is concerning but I will let someone else interpret it.

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Was the PIP of 36 (cmH2O) a typo? Or is this a high kPa? A PIP of 36 cmH20 is great for a PEEP of 22 cmH2O.

Did you mean Plateau Pressure (cmH2O) considering the vent setting (PEEP and tidal volume) CXR and fluid status?

Or is there a very large air leak.

The ABG is also questionable with a PaCO2 of 60 mmhg, BD of -11 mEq/L HCO3 of 9 mEq/L with a 7.40 pH.

For HgB, for clarification, that is 80 grams/liter or 8.0 grams/deciliter?

Have the results for the type of flu come back?

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Hello,

Sorry for the slow reply. I upgraded my computer at home and I can not figure out how to turn off the 'ad blockers' software and I can not login to EMT City. I will get my IT department (brother-in-law) to fix things for me.

Just as a side note, if you wait 30 seconds or so the adblocker warning should disappear allowing you to log into the site.

At least, that's what it does for me.

I agree with cutting back on the fent/versed. I, too, am questioning some of the values listed. Can we confirm them, please?

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I say kill the Propofol as well, how about ketamine for a while and see what the pressure does.

Has her blood been crossmatched? I'd love to get some hanging.... should do good things for pressure, as well as oxygen delivery.

Edited by mobey

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Still awaiting verification of labs.

I would be very cautious about blood products now given the positive fluid balance. If labs were drawn after lots of fliud the number could be misleadingly low.

Given the status of the kidneys and positive fluid balance, the paralytic should be the first to go if BP and ventilator holds steady. You also do not want this patient to wake up and buck the vent at any time during transport. You might ask the sending physician if this is his or her thoughts in preparation for transport. No need to repeat past mistakes.

Also, considering the fluid balance, is the lactate trending down and was the high lactate attributed to the cardiac arrest or sepsis?

Is the sending facility thinking dialysis to happen upon arrival at receiving facility? ECMO? Still dependent on clarification of ABG.

Edited by iStater

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