William Kent
last written: July 2011, David LaPierre
last reviewed:
introduction
William Kent is a 42 year-old man who is admitted to the surgical floor after a motor vehicle collision in which his femur was fractured. He was otherwise uninjured, other than some minor lacerations. He has no medical conditions.
At 1600 his vitals were normal, and he had no complaints. At 1630, his nurse finds him severely dyspneic and grey. She quickly checks his vitals, and finds HR 112, BP 80/40, RR 26, and oxygen saturation 82%.
What is your tentative diagnosis? How do you confirm the diagnosis on physical exam?
William likely has acute respiratory distress syndrome (ARDS), judging from the acute onset and absence of heart disease.
Physical exam findings should include:
- hyperdynamic pulses
- flat neck veins
- absent edema
What is your immediate management?
Provide supportive care. Supplemental oxygen should be given, with mechanical intubation considered.
Fluid recuscitation should be provided to restore perfusion using crystalloids.
What investigations do you order?
A chest X-ray and ECG should be ordered to assess for heart disease or underlying lung pathology.
Blood work should include:
- CBC
- electrolytes
- renal function tests
- arterial blood gases
After 2L normal saline is given IV, William's HR is 104 and BP is 88/58. His saturation remains 92% on a non-rebreather.
What further treatments do you consider?
Dobutamine may be used for cardiovascular support.
packed red blood cells may be given to increase oxygenation.
Transfer the patient to the ICU for further treatment and monitoring.
Investigations reveal:
- chest X ray: bilateral ground glass infiltration
- ABG with a PaO2/FiO2 ratio of 178
- Swan ganz catheter (placed in the ICU) shows a left ventricular end diastolic pressure of 16 mmHg
These indices confirm a diagnosis of ARDS in Mr Kent.
The team continues treatment and also begins a course of corticosteroids.
Mr Kent's oxygen saturation continues to slowly decrease over the next 24 hours, after which he begins to improve. He is extubated after 36 hours and is discharged back to surgery the next day to await repair of his femur.
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