hypoxia,respiratoryfailureandalteredmentalstatus[缺氧，呼吸衰竭和精神狀態(tài)改變](ppt-58)-資料下載頁
2025-01-12 07:14本頁面
【正文】 dioxide tension with respiratory acidosis Case Study 5 45 year old male in the ICU admitted four days ago with necrotizing pancreatitis. He was intubated on admission. His current ventilator settings are IMV rate of 14, tidal volume 600 mL, PEEP 5 and FiO2 50%. The nurse calls you because after the patient was turned and washed he desaturated to 70%. She has already turned the FiO2 up to 100% and his saturation has not responded. Differential Diagnosis Differential Diagnosis ? Pneumonia ? Lobar collapse ? Pneumothorax ? Pulmonary embolus ? Aspiration ? Sepsis ? Pulmonary edema ? Mucous plugging ? Bronchospasm ? ETT is dislodged What do you do? ? Take patient off the ventilator and hand bag 187。 Rule out ventilator problem 187。 Assess degree of airway resistance ? Listen to the lungs 187。 Rule out pneumothorax, fluid overload, bronchospasm ? Order a CXR, ABG 187。 ABG will be bad, but will assess acidosis, and ventilation 187。 CXR will assess ETT placement, lobar collapse, effusion, pneumonia, etc. 187。 Does patient require bronchoscopy? ? Pass a suction catheter 187。 Rule out an occluded, dislodged ETT and assess secretions ? Give a bronchodilator 187。Can’t hurt! May loosen secretions ? If chest tubes in place, make sure on suction and assess for air leak ? Adjust ventilator to pensate worsening respiratory failure History and Physical Exam Diagnosis Operation performed CoMorbidities Age Chest Xray Lab Electrolytes Arterial Blood Gass Pulse Oximetry Sa02 90% Sa02 90% Remains agitated and risk for withdrawal (alcohol +/or drug) May sedate with Shortacting benzodiazepine or haldol Step 1 Assess Airway Step 2 Step 3 Assess Circulation Intubated Not intubated ETT good position Check CXR (go to step 2) Reintubate intubate Hemodynamically stable Assess Breathing Hemodynamically unstable with ? breath sounds Check CXR, ABG Tube thoracostomy Pulses absent ACLS protocol Pulses present Assess cardiac status ie. arrythmias Labs amp。 ABG normal ETT dislodged Minineuro exam Review chart for medications Consider need for CTH Call for Altered Mental Status Desaturation or Respiratory distress ASSESS PATIENT ARDS ? A patient must meet all of the following: – Acute onset of respiratory symptoms – CXR with bilateral infiltrates – No evidence of left heart failure – PaO2/FiO2 200mm Hg (regardless of PEEP) – AmericanEuropean Consensus Conference on ARDS (Am J Resp Crit Care Med 149:818, 1994) ? The following are implied: – Previously normal lungs – Decreased lung pliance – Increased shunting – Hypoxemic respiratory failure
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