TY  - CHAP
M1  - Book, Section
TI  - Case Study 11
A1  - Hoffman, Robert S.
A1  - Howland, Mary Ann
A1  - Lewin, Neal A.
A1  - Nelson, Lewis S.
A1  - Goldfrank, Lewis R.
Y1  - 2015
N1  - 
T2  - Goldfrank's Toxicologic Emergencies, 10e
AB  - HistoryA  rapid  response  team  (RRT)  was  called  to  the  endoscopy  suite  because  a  patient  developed  shortness  of  breath  and  decreased  oxygen  saturation.  On  arrival,  the  responders  found  a  55  year-old  man  with  the  following  vital  signs:  blood  pressure,  166/112  mm  Hg;  pulse,  142  beats/min;  respiratory  rate,  40  breaths/min;  oxygen  saturation,  87%  on  4  liters/minute  of  oxygen  via  nasal  cannula.  The  man  had  a  history  of  Barrett's  esophagus  and  obstructive  sleep  apnea  (OSA)  and  had  to  undergo  periodic  upper  gastrointestinal  endoscopy  as  a  screening  procedure  for  cancer.The  gastroenterologist  who  called  the  RRT  reported  that  the  patient  had  no  complaints  during  the  pre-procedural  time  out  and  that  the  following  vital  signs  had  been  recorded:  blood  pressure,  142/88  mm  Hg;  pulse,  88  beats/min;  respiratory  rate,  16  breaths/min;  tympanic  temperature,  97.6°F  (36°C);  and  oxygen  saturation,  99%  on  room  air.  Just  prior  to  administration  of  conscious  sedation,  the  patient  became  uncomfortable  and  complained  of  shortness  of  breath.  Within  a  few  minutes  his  vital  signs  deteriorated  and  he  became  cyanotic.Immediate  Assessment  and  ManagementThe  patient  was  immediately  given  high  flow  oxygen  via  a  100%  nonrebreather  mask,  and  although  his  respiratory  rate  and  pulse  improved  somewhat,  his  oxygen  saturation  remained  between  86%  and  88%.  Physical  examination  was  notable  for  an  ill  appearing  man  who  could  only  speak  in  short  sentences.  Although  he  denied  chest  pain,  review  of  systems  was  positive  for  headache  and  nausea.  His  skin  and  nailbeds  were  cyanotic,  his  chest  was  clear,  and  his  heart  was  regular  and  tachycardic  without  extra  sounds.  The  patency  of  his  intravenous  line  was  confirmed,  and  an  electrocardiogram  was  obtained  and  showed  sinus  tachycardia  without  ST  segment  or  T  wave  changes  suggestive  of  ischemia  or  infarction.  When  he  failed  to  respond  to  supplemental  oxygen,  he  was  moved  to  the  emergency  department  (ED).On  arrival  to  the  ED,  the  following  vital  signs  were  obtained:  blood  pressure,  152/104  mm  Hg;  pulse,  122  beats/min;  respiratory  rate,  32  breaths/min;  tympanic  temperature,  97.8°F  (36.5°C);  oxygen  saturation,  88%  on  100%  oxygen;  and  end  tidal  CO2,  28  mm  Hg.What  Is  the  Differential  Diagnosis?This  patient  presented  with  hypertension,  tachycardia,  tachypnea,  cyanosis,  and  decreased  oxygen  saturation.  The  most  common  causes  for  these  findings  are  cardiac  and  pulmonary  disease.  Hypoxia  and  cyanosis  in  a  normal  environment  (breathing  a  normal  FiO2)  can  result  from  a  shunt,  ventilation-perfusion  mismatch,  diffusion  abnormalities,  or  pump  failure  (Chaps.  17  and  29).  The  absence  of  underlying  heart  disease,  unremarkable  electrocardiogram,  pulse  and  blood  pressure  that  is  adequate  for  tissue  perfusion,  and  clear  chest  examination  essentially  excludes  these  disorders,  although  laboratory  and  radiologic  confirmation  should  be  obtained  (see  following  sections).  When  cardiac  and  pulmonary  disorders  are  excluded,  dyshemoglobinemias  should  be  considered,  specifically  methemoglobinemia  and  sulfhemoglobinemia  (Chap.  127).What  Immediate  Diagnostic  and  Therapeutic  Interventions  Are  Indicated?The  patient  was  maintained  on  100%  oxygen,  and  bilevel  positive  airway  pressure  (BiPAP)  was  started  while  preparations  were  made  for  endotracheal  intubation.  Reasonable  initial  testing  would  include  a  chest  radiograph,  bedside  echocardiogram,  and  an  arterial  blood  gas  (ABG)  analysis.  In  many  sections  of  this  book  the  relationship  between  a  venous  blood  gas  (VBG)  and  an  ABG  are  discussed  ...
SN  - 
PB  - McGraw-Hill Education
CY  - New York, NY
Y2  - 2024/04/18
UR  - accessemergencymedicine.mhmedical.com/content.aspx?aid=1108439053
ER  -