Case Study: Fever - Page 3Register Today!
- Jun 24 by juan de la cruzQuote from jadelpnABG's give a lot of information. Acid-base balance is one. It also lets us know how adequate oxygenation and ventilation are. In the initial ABG, the pH is 7.40 which is in the middle (range is 7.35-7.45), bicarbonate is not really low so no metabolic component. PCO2 tells us about ventilation which 37 is within normal. Many posters already alluded to the profound hypoxemia (low PO2).PCO2 a little high (?) so no increase in the oxygen to decrease drive....
Also, not entirely thrilled with the glucose #. Not awful, but it is glaring out at me--
OP, quick guide on acidosis/alkaline.....is this pertainant to this case?
- Jun 25 by juan de la cruzGreat responses!
A rapid HIV screen was done given the concern for an immunocompromised state that might have brought on an overwhelming and diffuse infectious pulmonary process based on the CXR and the profound hypoxemia. The result was negative. RPR was also sent and was negative.
And yes, the ED team decided to intubate because of the profound hypoxemia and increased work of breathing noted. The CXR findings were more consistent with an infectious process rather than pulmonary edema. But before I proceed, a note about intubation vs trial of BiPAP:
Many physicians are using BiPAP as a bridge in patients who presents with acute respiratory difficulties to avoid intubation. This website does a good job explaining this modality and how to make decisions when one is stuck between intubating and seeing if BiPAP could improve the clinical picture: BiPAP vs intubation
Back to the case:
The ED physicians spoke to Rolando and his father about the need to intubate. Both were agreeable with the plan and wanted to do everything possible to help Rolando.
A rapid sequence intubation followed. You will be assisting with this. A question, for the ED nurses in community hospital settings, what are your roles in this procedure? do you administer induction agents (Opioid/Hypnotic and Paralytics)? Just thought I'd ask.
Rolando's Vital Signs before intubation were: Temp 38.5, HR 120, RR 37, BP 140/80, O2sat 92% on HFNC at 40 LPM.
The physician decided to use Propofol and Succinylcholine for induction. Continuous monitoring equipment was made available and was checked that they were working. These included: continuous telemetry, continuous pulse oximetry, non-invasive BP cuff cycling at q 1 minute, and end-tidal CO2 monitor. You have placed two Gauge 18 peripheral IV's on each of Rolando's upper extremities and you have a bag of 0.9 NaCl 1L attached to one of his IV sites.
The physician placed a well-fitting ambu-bag mask with a tight seal over Rolando's face. He began to deliver breaths to pre-oxygenate, a technique performed prior to intubation the purpose of which is to flood the lung's functional residual capacity with increased oxygen levels so that enough reserve is available while the patient is paralyzed and not breathing during insertion if the oral endotracheal tube.
After administering Propofol and Succinylcholine IV, patient was intubated successfully. Condensation was noted inside the breathing tube, end-tidal CO2 was 30, and bilateral breath sounds were heard over the patient's lungs. The endotracheal tube was secured by the Respiratory Therapist. Subsequent CXR revealed the Endotracheal Tube's tip to be 3 cm above the carina.
The physician wanted to start with Assist Control, Volume Cycled Mechanical Ventilation. Rolando is 5 feet 8 inches tall. His orders were: Set Rate 20/min, Tidal Volume 500, FiO2 100%, PEEP 5. Propofol IV infusion was started. Immediately after intubation his vital signs changed to:
Temp: 38.3, HR 100, RR 20, BP 85/40, O2 sat 96% on the above ventilator settings.
What could possibly explain these changes and what would you anticipate next?
- Jun 25 by HazelGraceI'm a student so bear with me.
I'm thinking he has lead or pesticide poisoning that is causing hemolytic anemia. Perhaps he inhaled pesticides--Central Valley is known for agriculture. Also rash at shin level suggests leaning up against bushes; perhaps to harvest something or he was walking and spraying pesticides at knee level. WBCs are elevated to clear the particles and that could be the infiltrates seen on the cxr. I'm not sure if giving more oxygen or preparing for intubation is wise; he has good ventilation but poor carrying capacity. I'd anticipate orders for packed RBC and chelating therapy.
What business is his father in? Where do they live/farms nearby that do crop dusting?what home remedies have they tried?
- Jun 25 by jadelpnOoooooo, this is interesting.
In our ED, CRNA's are the only ones besides the MD's that can intubate in the ED setting.
Because the patient could actively participate in the initial conversation regarding intubation, and typically a young, healthy person, then I would have suspected a bit more propofol was used to sedate to the point of intubation. To decrease the propofol would be tricky, as there would have to be a balance so patient is sedated but not over sedated. Patient is 5'8", however, what kg is patient?
I would decrease the drip a bit, see if the BP comes up and PR comes down a bit.
Changes in vitals such as this would point to a possibility that patient is going into shock, with a low BP and increased pulse rate. Which may not have a thing to do with the intubation, and more to do with the infectious process.
Stat pulmonary consult, to get a start on broad scope antibiotics to attempt to turn this around.
- Jun 25 by TomGuyNot an ED nurse.. But I'll give this a shot. There are certain things that are "glaring" at me when I read this.
1) Just moved to Central Valley, new job with father in a "small business" (that's a clue), Philipino decent
2) Mild respiratory distress, Joint pain, BILATERAL SHIN RASH
After the first post, it's still hard to know what could be going on but I knew those facts were important
Second post - Things that stood out
1) Chest X-ray abnormal, you stated it was consistent with bacterial infx
2) Elevated WBC - Infectious process going on
3) Increasing respiratory distress only after 1 hour under your care
Patient is going from mild respiratory distress to acute, he has Chest X-ray that is consistent with bacterial infx. Now at this point it could still be anything, but I don't think pneumonia, influenza has this kind of presentation especially with a young healthy man. The difference here is that he just moved to Central Valley with his father and is working at his business. Why was this screaming at me? I don't know. I cheated a little and googled Central Valley, Flu, rash, joint pain or some kind of combo, and Valley Fever popped up.
Valley fever is caused by a fungus called Coccidioides immitis or Coccidioides posadasii that thrive in desert soils. The case presentation is consistent with Valley Fever: Rash, Fever, Joint pain, chest pain, abnormal chest x-ray etc. I'm willing to bet the father either works in construction or landscaping that has exposed the patient to this fungus.
Culture would need to be obtained to confirm diagnosis, IV antifungals should be started after positive culture returns, IV fluids, tx of symptoms, monitor pain levels.
As for the third post, pre intubation the patient was in respiratory distress and had increased RR to compensate for his inadequate pulmonary function. Post intubation the patient's ventilations are set to 20 so his RR will read 20 (I think?), his HR is lower because he is no longer in distress and/or because the sedating effects of propofol. I believe propofol is causing the b/p to drop although IMMediately post intubation I do not think it is a reason for alarm. Monitor patient vital signs q5min for at least 30mins and if b/p does not go up then consider titrating propofol.
- Jun 25 by SwansonRNI don't think anyone should be surprised that Rolando dropped his pressure. Like I said earlier he has been feeling sick for a while, tachypneic, probably is infected and just got sedated. Run those fluids in! Titrate down propofol as tolerated. Once patient's pressure is up a little roll him on over to the ICU. If he doesn't respond to fluid resuscitation he'll probably get lined for pressors and to check a CVP. An a-line would be good for labile blood pressures and frequent ABGs. Now that he has an ETT maybe we could do a bedside bronch once he stabilizes. He should be getting broad spectrum antibiotics at this point and coverage for fungal source (fluconazole?).
- Jun 25 by GrnTeaQuote from juan de la cruzCentral Valley, huh? Hypoxia without hypercarbia? Valley fever.Rolando was appropriately triaged as emergent and was placed on Airborne Precautions in negative room pressure. The triage nurse appropriately secured an order for high flow nasal cannula. You are now his nurse in the ED.
Orders were for:
Respiratory Viral Panel, Sputum bacterial and gram stain, Legionella serum Ab, Pneumococcal serum Ag, Sputum for AFB. You were able to send all the appropriate specimens for these tests.
You were also asked to obtain ABG with lactate, CBC, Basic Metabolic Panel, and Coagulation Studies. Blood cultures were ordered. UA with tox screen was also ordered.
A portable CXR was obtained.
Available labs revealed:
Ph 7.40 pCO2 37 pO2 56 HCO2 22 BE 0 Sat 90% Lactate 2.5 on HF at 100% FiO2
WBC 18,000 Hgb 16 Hct 48 Plt 300 (+) Eosinophilia
Na: 140 K 4.0 Cl 100 CO2 22 BUN 15 Crea 0.5 Gluc 87
PT 14 INR 1.1 PTT 23
negative for UTI or drugs
Rolando is working a bit harder to breathe after 1 hour of being under your care. What would you anticipate next?
- Jun 25 by GrnTeaQuote from GrnTeaI tried to edit but got frozen out somehow. I meant to continue:Central Valley, huh? Hypoxia without hypercarbia? Valley fever.
I didn't read any other comments before posting, I swear. I lived in CA and saw this presentation often. I'm thinking this poor boy buys himself a lot of sedation and an FIO2 of 1.0 and all the PEEP he can handle to get his FIO2 down and his PaO2 up. He gets amphoterrible or whatever else is specific for mycoses these days. If he is lucky he does not end up in a box.