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#Ogitorial No35: hypothetical 41F #COVID19 intubated after failing NIV trial (24h).
A ETT 25cm
B SpO2 82% FiO2 1 Vt350 P12
❤️BP 110/80 HR 95, CapRef 1.5”
D avpU (propofol)
E Obese, no rash, soft abdomen
U bil B lines, RV=LV, EF~60%,
L pH 7.29, PCO2 35, Cr 1.4, Lactate 2.2 Hb10
A ETT 25cm
B SpO2 82% FiO2 1 Vt350 P12
❤️BP 110/80 HR 95, CapRef 1.5”
D avpU (propofol)
E Obese, no rash, soft abdomen
U bil B lines, RV=LV, EF~60%,
L pH 7.29, PCO2 35, Cr 1.4, Lactate 2.2 Hb10
Patient got remdesivir & dexamethasone. SpO2 88% after bolus NMB & pulling ETT(3cm). As you increase PEEP to 18, driving pressure improves, but the SpO2 drops to 72% without hypotension. You decrease PEEP back to previous but SpO2 still 70s. The next step is: #FOAMcc #MedTwitter
1/ With inhaled NO SpO2 improved to 97%, and after 2h FiO2 was down to 40% and rapid weaning.
Bubble study confirms suspected intermittent #PFO shunt which occurs in up to 19% #ARDS with ⬆️rescue Rx & ⬇️VFD
pubmed.ncbi.nlm.nih.gov/20601861/
pubmed.ncbi.nlm.nih.gov/33252722/
pubmed.ncbi.nlm.nih.gov/33150525/
Bubble study confirms suspected intermittent #PFO shunt which occurs in up to 19% #ARDS with ⬆️rescue Rx & ⬇️VFD
pubmed.ncbi.nlm.nih.gov/20601861/
pubmed.ncbi.nlm.nih.gov/33252722/
pubmed.ncbi.nlm.nih.gov/33150525/
1/#Ogitorial No21 Real Patient with Consent. 42M, previously healthy collapses upon entering ED
A ok
B clear, bag/maskFiO2
♥️ BP 60/, HR80 Epi drip
D avPu
E punctate skin marks, diaphoresis, ashen skin, L eyelid swell
U - dark ages
L Hb10, WBC6,K 2, Na146, HCO3 12, Lact 2.4-4.5
A ok
B clear, bag/maskFiO2
♥️ BP 60/, HR80 Epi drip
D avPu
E punctate skin marks, diaphoresis, ashen skin, L eyelid swell
U - dark ages
L Hb10, WBC6,K 2, Na146, HCO3 12, Lact 2.4-4.5
You place (just in case) DC pads, replace K/Mg. ED volunteer says: prior to collapsing, the patient mumbled “bees”. You speed up fluid (5LNS/1h), add steroid & H1/H2 blocker with ⬆️BP but severe rigors, anxiety & delirium. The risk of future PTSD is best ⬇️ by:
#FOAMed #FOAMcc
#FOAMed #FOAMcc
3/ #Ogitorial No21 answer
Psychological sequelae of critical illness are common & important
ncbi.nlm.nih.gov/pubmed/25449881
Dex is not safe in patients on Epi drip & no evidence it can help.
Diaries ncbi.nlm.nih.gov/pubmed/30431494 &
Post-ICU clinics ncbi.nlm.nih.gov/pubmed/25731633
are of limited help
Psychological sequelae of critical illness are common & important
ncbi.nlm.nih.gov/pubmed/25449881
Dex is not safe in patients on Epi drip & no evidence it can help.
Diaries ncbi.nlm.nih.gov/pubmed/30431494 &
Post-ICU clinics ncbi.nlm.nih.gov/pubmed/25731633
are of limited help
