A patient arrives in the emergency department following a motor ...

[Deast7027]

A patient arrives in the emergency department following a motor vehicle accident in which the patient sustained a deceleration chest injury.
 
  The patient was intubated in the field for airway protection. Physical assessment reveals that the patient is spontaneously breathing at a rate of 16 breaths/min, and breath sounds reveal bibasilar fine crackles at end inspiration. A second arterial blood gas was drawn while the patient was re-ceiving 100 oxygen from an air entrainment large volume nebulizer.
  Parameter 9:35 PM 10:10 PM
  pH 7.53 7.50
  PaCO2 (mm Hg) 27 30
  PaO2 (mm Hg) 48 56
  SaO2 () 90 91
  HCO3 (mEq/L) 24 24
  Supplemental oxygen Room air 100 Bland aerosol
  The most appropriate recommendation for this patient is which of the following?
  a. Continuous positive airway pressure (CPAP) with supplemental oxygen
  b. Pressure-controlled inverse ratio ventila-tion (PCIRV) with positive end-expiratory pressure (PEEP) and sedation
  c. Volume-controlled continuous mandatory ventilation (VC-CMV)
  d. Airway pressure release ventilation (APRV)

Question 2

A patient with acute respiratory distress syndrome (ARDS) has developed a pneumothorax from elevating peak and plateau pressures.
 
  The patient is currently being ventilated in the volume-controlled continuous mandatory ventila-tion (VC-CMV) mode with a set rate of 12 breaths/min. However, the patient is triggering the ventilator at a rate of 25 breaths/min. The arterial blood gas reveals ventilator-induced hyperven-tilation with corrected hypoxemia. The most appropriate recommendation to manage this patient on the ventilator is which of the following?
  a. Sedate the patient.
  b. Decrease the set ventilator rate.
  c. Switch the mode to pressure-controlled intermittent mandatory ventilation (PC-IMV).
  d. Switch the mode to pressure-controlled continuous mandatory ventilation (PC-CMV).

[kswal303]

Answer to Question 1

ANS: A
Both the assessment and blood gas results reveal that the patient is spontaneously breathing. However, it appears that the patient is suffering from air hunger. The blood gases reveal that the patient has refractory hypoxemia. With this information, the most appropriate recommenda-tion would be to place the patient on continuous positive airway pressure (CPAP) with supple-mental oxygen to improve the refractory hypoxemia by opening up atelectatic areas and main-taining them open. Since the patient is breathing spontaneously, mechanical ventilator breaths are not necessary.

Answer to Question 2

ANS: C
Switching to pressure-controlled ventilation will reduce the continued risk of alveolar overdisten-tion, which has already caused a pneumothorax, by limiting the amount of positive pressure ap-plied to the lung. Using the intermittent mandatory ventilation (IMV) mode will decrease the ability of the patient to cause ventilator-induced hyperventilation by triggering mandatory breaths. IMV, with a low ventilator rate setting, can very well reduce this patient's respiratory alkalosis. Using pressure support with the pressure- controlled intermittent mandatory ventilation (PC-IMV) mode will decrease the WOB for the patient during spontaneous breaths.

[Deast7027]

Thanks for the timely response, appreciate it

[miss.ashley]

Gracias!