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
Examination Library
CICM
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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