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Hypoxia, Respiratory Failure and Altered Mental Status

Hypoxia, Respiratory Failure and Altered Mental Status. Alicia M. Mohr, MD Surgical Fundamentals Session 2 July 23,2010. Objectives. To learn a logical method for determining the nature of respiratory failure and its treatment To determine if a patient requires intubation and ventilation

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Hypoxia, Respiratory Failure and Altered Mental Status

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  1. Hypoxia, Respiratory Failure and Altered Mental Status Alicia M. Mohr, MD Surgical Fundamentals Session 2 July 23,2010

  2. Objectives • To learn a logical method for determining the nature of respiratory failure and its treatment • To determine if a patient requires intubation and ventilation • To learn the differential diagnosis and treatment of altered mental status

  3. May sedate with Short-acting benzodiazepine or haldol Labs & ABG normal History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Remains agitated and risk for withdrawal (alcohol +/or drug) Check CXR (go to step 2) Consider need for CTH ETT good position Mini-neuro exam Review chart for medications Intubated Re-intubate ETT dislodged Step 1 Assess Airway Call for Altered Mental Status Desaturation or Respiratory distress Sa02 > 90% Not intubated intubate ASSESS PATIENT Hemodynamically stable Step 2 Check CXR, ABG Pulse Oximetry Sa02 < 90% Assess Breathing Hemodynamically unstable with  breath sounds Tube thoracostomy Step 3 Assess Circulation Chest X-ray Lab Electrolytes Arterial Blood Gass Pulses absent ACLS protocol Pulses present Assess cardiac status- ie. arrythmias

  4. History ?

  5. Can’t catch my breath Lightedheadedness Usually acute onset Minimal symptoms History

  6. Physical Exam Findings ?

  7. Tachypnea Dyspnea Retractions Nasal flaring Grunting Diaphoresis Tachycardia Hypertension Physical Exam Findings • Altered mental status • Confusion • Agitation • Restlessness • Somnolence • Cyanosis (need 5mg/dl of unoxygenated blood)

  8. Case Study #1 59 year old man underwent a Whipple two days ago. You are called because he developed a sudden onset of dyspnea and he desaturated. His temp is 37.3o, his HR is 120, RR 24 and BP 80/50. He is anxious with decreased breath sounds at bilateral bases.

  9. Oxygen delivery to tissues Carbon dioxide removal from tissues A - Airway B - Breathing C - Circulation Assess, change, reassess

  10. Case Study #1 Signs of respiratory distress Nasal flaring Sternal retractions Tripoding Use of accessory muscles Tachypnea Cyanotic Anxiety, restlessness

  11. Case Study #1 • His CBC and lytes are normal • ABG pH 7.45 PaCO2 28 mmHg PaO2 72 mmHg • CXR shows mild left lower lobe atelectasis ?

  12. Indications for Intubation ?

  13. Indications for Intubation • Airway protection Loss of gag reflex, GCS <8 Massive facial trauma 2. Failure to ventilate Increased work of breathing PaCO2 > 55 mm Hg 3. Failure to oxygenate Hypoxemia or PaO2 < 60 mm Hg Severe metabolic acidosis or shock Need for bronchopulmonary toilet

  14. The Decision to Intubate

  15. Indications for Intubation • The decision to intubate or not intubate a patient can be a life or death decision • It should not be taken lightly! • However, most times you will ask yourself-’Have you ever regretted intubating a patient?’ • The most likely response is that you have regretted NOT intubating a patient • IF YOU THINK ABOUT INTUBATING A PATIENT YOU SHOULD PROBABLY DO IT!

  16. Rapid Sequence Intubation Establish IV Preoxygenate patient Apply cricoid pressure Administer etomidate 0.3 mg/kg IV Administer succinylcholine 1.5 mg/kg IV CAVEAT: For most emergent intubations medications are not required or not available! INTUBATE Do not release cricoid pressure until cuff inflated and tube placement verified Auscultate bilaterally to verify tube placement Use CO2 detector to assure tube placement Secure endotracheal tube

  17. Case Study #1 • His CBC and lytes are normal • ABG pH 7.45 PaCO2 28 mmHg PaO2 72 mmHg • CXR shows mild left lower lobe atelectasis ?

  18. Pathophysiology of Respiratory Failure Due to mismatch of ventilation and perfusion in lung units

  19. May sedate with Short-acting benzodiazepine or haldol Labs & ABG normal History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Remains agitated and risk for withdrawal (alcohol +/or drug) Check CXR (go to step 2) Consider need for CTH ETT good position Mini-neuro exam Review chart for medications Intubated Re-intubate ETT dislodged Step 1 Assess Airway Call for Altered Mental Status Desaturation or Respiratory distress Sa02 > 90% Not intubated intubate ASSESS PATIENT Hemodynamically stable Step 2 Check CXR, ABG Pulse Oximetry Sa02 < 90% Assess Breathing Hemodynamically unstable with  breath sounds Tube thoracostomy Step 3 Assess Circulation Chest X-ray Lab Electrolytes Arterial Blood Gass Pulses absent ACLS protocol Pulses present Assess cardiac status- ie. arrythmias

  20. Case Study #2 22 year old man was admitted five days ago after an MVC. He sustained a left rib fractures, a left pneumothorax and a left femur fracture. The nurse states the patient is short of breath. His temp is 37.1o, his HR is 95, RR 30 and BP 120/70. His saturation on room air is 85%

  21. Differential Diagnosis ?

  22. Differential Diagnosis • Pneumothorax • Pneumonia • Lobar collapse • Pulmonary embolus

  23. Case study #2 • When the situation is not life threatening there is ample time to perform the necessary diagnostic tests and manuevers • In a life threatening situation immediate action is necessary to prevent arrest • For example, if you suspect someone has a tension pneumothorax as a life saving manuever you should perform needle decompression with a 14 gauge angiocath rather than wait for a tube thoracostomy and scalpel, etc.

  24. May sedate with Short-acting benzodiazepine or haldol Labs & ABG normal History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Remains agitated and risk for withdrawal (alcohol +/or drug) Check CXR (go to step 2) Consider need for CTH ETT good position Mini-neuro exam Review chart for medications Intubated Re-intubate ETT dislodged Step 1 Assess Airway Call for Altered Mental Status Desaturation or Respiratory distress Sa02 > 90% Not intubated intubate ASSESS PATIENT Hemodynamically stable Check CXR, ABG Pulse Oximetry Sa02 < 90% Step 2 Assess Breathing Hemodynamically unstable with  breath sounds Tube thoracostomy Step 3 Assess Circulation Chest X-ray Lab Electrolytes Arterial Blood Gass Pulses absent ACLS protocol Pulses present Assess cardiac status- ie. arrythmias

  25. Case Study #3 72 year old man was admitted two days ago after an assault. He sustained an orbital fracture, scalp laceration and a frontal contusion. The nurse states the patient is confused and restless. ?

  26. Case Study #3 What do you want to know? • Is this a change in his mental status? • Was he just medicated? • Has this happened before? • What are his vital signs? • What is his saturation?

  27. Altered Mental Status Five major causes: • Metabolic derangement • Drug toxicity/overdose/withdrawal • Infectious • Strutural abnormality • Psychiatric

  28. Altered Mental Status Metabolic abnormality • Rule out hypoxia • Check ABG, saturation • Rule out hypoglycemia, DKA • Assess blood glucose • Rule out uremia • Assess urine output, BUN, creatinine • Rule out hepatic encephalopathy • Check ammonia • Rule electrolyte abnormalities • Send electrolytes

  29. Altered Mental Status Structural abnormality • Assess GCS • Assess for suspected head injury • Assess for focal neurologic deficits • Assess for possible post-ictal state • Emergent CT head

  30. Altered Mental Status Infectious cause • Assess for post operative sepsis • Assess risk of meningitis • Assess need for CT

  31. Altered Mental Status Drug toxicity/overdose/withdrawal • Assess recent prescribed medications • Assess for potential self prescribed medications • Check pupils • Check for sweating, agitation, hallucinations • Assess HR and blood pressure • May prescribe narcan or naloxone if OD • May prescribe benzodiazepine if withdrawal

  32. Altered Mental Status

  33. Altered Mental Status Psychiatric cause • Assess for hallucinations • Assess for delusions • Mini-neuro exam

  34. May sedate with Short-acting benzodiazepine or haldol Labs & ABG normal History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Remains agitated and risk for withdrawal (alcohol +/or drug) Check CXR (go to step 2) Consider need for CTH ETT good position Mini-neuro exam Review chart for medications Intubated Re-intubate ETT dislodged Step 1 Assess Airway Call for Altered Mental Status Desaturation or Respiratory distress Sa02 > 90% Not intubated intubate ASSESS PATIENT Hemodynamically stable Step 2 Check CXR, ABG Pulse Oximetry Sa02 < 90% Assess Breathing Hemodynamically unstable with  breath sounds Tube thoracostomy Step 3 Assess Circulation Chest X-ray Lab Electrolytes Arterial Blood Gass Pulses absent ACLS protocol Pulses present Assess cardiac status- ie. arrythmias

  35. Case Study #4 70 year old female had a colon resection five days ago. You are called by the nurse because she is dyspneic. Her temp is 100o, her RR is 30, her HR is 110, and her BP is 140/90. Her saturation is 95% on a non-rebreather.

  36. Differential Diagnosis ?

  37. Differential Diagnosis • Pneumonia • Lobar collapse • Pulmonary embolus • Aspiration • Sepsis • Pulmonary edema • Congestive heart failure • Myocardial infarction

  38. Case Study #4 Causes of post-operative dyspnea • Rule out pneumonia, atelectasis, collapse, aspiration • Check ABG, saturation, CXR • Assess abdomen, need for NGT • Rule out sepsis • Assess for fever, abdominal exam, CTA/P • Rule out pulmonary embolus • Assess leg swelling, duplex, CT chest • Can heparin be started empirically? • Rule out myocardial infarction • Check EKG, troponin, myocardial enzymes • Can aspirin be given? • Rule out fluid overload, CHF • Listen to lungs, assess fluid balance • Check home medications • Give diuretic

  39. Case Study #4 Does this patient need to be moved to monitored bed or ICU? • Does this patient require intubation now? • May this patient need to be intubated in the next few hours? • How likely is it that the patient is having an MI? • Is the patient having an arrythmia? • Does the patient need invasive monitoring? • How likely is it that the patient is going to decompensate? • How likely is it that I am going to be presenting this at M&M?

  40. Criteria for ICU assessment Threatened airway Respiratory arrest Respiratory rate >30 or <8 breaths / min Oxygen saturation <90% on >50% oxygen Cardiac arrest Pulse rate <60 or >140 beats / min Systolic blood pressure < 90 mmHg Sudden fall in level of consciousness Repeated or prolonged seizures Rising arterial carbon dioxide tension with respiratory acidosis

  41. 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. ?

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