Exploring Oxygenation Issues

To help you get ready for your next ACLS certification exam, we’ve prepared a case study scenario that involves an issue with a patient’s oxygenation.  Read the synopsis below, then take the case study quiz and view the correct answers.

 

SYNOPSIS

A 50-year-old male is admitted to your department cyanotic and gasping for breath. His skin is cold and diaphoretic. His vital signs are:

 

VITALS

• Temperature = 36.9c

• BP = 198/110

• Pulse = 122

• Respiratory frequency = 42/minute

 

There are bilateral inspiratory crackles heard, which do not clear with cough. His pulse oximetry is 71%. Bilateral 4+ jugular-venous distention is present. The EMT states that his daughter advised he has “heart failure.”

 

LAB RESULTS

ABGs are drawn and sent to the lab. The results are:

 

• pH = 7.28

• paC02 = 46mmHg

• pa02 = 102mmHg (patient receiving high concentration oxygen via a facemask with reservoir bag)

• sa02 = 66%

 

ADDITIONAL FINDINGS

Findings that support a diagnosis of CHF:

 

1. Past diagnosis of “heart failure”
2. Tachypnea (response to lung stiffness, hypoxia, lactic acidosis, possibility anxiety)
3. Increased work of breathing  (stiff/non-compliant lung tissue)
4. Cyanosis (oxygenation failure due to poor cardiac output/increased pressure from fluid being forced from the capillaries back into the alveolus)
5. Diaphoresis/cold skin (inadequate peripheral perfusion, sympathetic discharge)
6. JVD (severely increased cardiac filling pressures)
7. Inspiratory lung crackles not clearing with cough (alveolar fluid caused by increased hydrostatic pressure gradients)

 

WHAT WOULD YOU DO?

Based on your understanding of the case study scenario, choose the best answer for each of the questions below.

 

1. OXYGENATION

A. Sedate, intubate and ventilate with 100% oxygen

B. Administer a small volume nebulizer with a bronchodilator

C. Begin CPAP via facemask (Fi02 = 40%) increasing the pressure 2 cm/h20 until you observe slowing of the respiratory frequency – repeat ABG

D. Start of a nasal cannula at 6 lpm

2. TACHYPNEA

A. Sedate with IV morphine

B. Paralyze, intubate and control ventilation

C. CPAP by facemask titrated up until you see a reduction in respiratory frequency

D. Any of the above are acceptable

3. CYANOSIS

A. Observe skin color as CPAP is titrated

B. Increase Fi02 and assist ventilate if patient becomes suddenly unstable

C. If improvement observed, repeat ABG

D. All of the above

4. PERFUSION

A. Reduce left ventricular filling pressure (carefully titrated vasodilator)

B. Consider inotropic support

C. Aggressive diuretic therapy

D. A & B only