CICM SAQ 2010.1 Q28

Question

A 65 year old male with a past history of ischaemic heart disease is admitted to the ICU after a motorcycle crash having sustained long bone fractures of the lower limbs. He has no head, chest or abdominal injuries. Prior to surgery, his GCS was 15 and SpO2 was 98% on 4l oxygen via Hudson mask with a normal chest X-Ray. He required prolonged operative fixation of his fractures and that was complicated by significant blood loss. Intra-operatively, he also developed increasing oxygen requirement. On arrival in ICU, his most recent arterial blood gas on an FiO2 of 0.7 shows a PaO2 55 mmHg.

  • 28.1.  List the differential diagnoses for his respiratory failure.
  • 28.2.  What assessment and investigations would you perform to help establish the diagnosis?

Answer

Answer and interpretation

28.1.  List the differential diagnoses for his respiratory failure.

  • Iatrogenic fluid volume overload due to blood product/resuscitation fluid
  • Atelectasis/Collapse/sputum plugging
  • Unrecognised pulmonary contusions
  • Unrecognised pneumothorax – Mech vent, line insertion
  • Aspiration at time of MBA or at intubation
  • Endobronchial intubation
  • Transfusion related acute lung injury (TRALI)
  • Cardiogenic pulmonary oedema/myocardial event
  • Fat embolism syndrome
  • Anaphylaxis
  • PE

28.2.  What assessment and investigations would you perform to help establish the diagnosis?

Clinical examination

  • Ensure adequate tertiary survey
  • Detailed respiratory examination
  • Review fluid balance and urine output
  • Evidence of generalised allergic reaction

Investigations

  • FBE – Hb, WCC, eosinophilia
  • Coags – ongoing coagulaopathy,
  • CXR – infiltrates, ETT position, hardware, PTx, pleural effusions
  • Cardiac enzymes – TnI
  • ECG – ischaemic changes, arrhythmia, R heart strain
  • Echocardiogram – if suspect cardiogenic component, assess LVF, or RVF for PE
  • CTPA – early for PE but possible if pt delayed in ED Bronchoscopy – if evidence of localised collapse or unexplained infiltrates

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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