Hypoxia, Respiratory Failure and Altered Mental Status

1
Hypoxia, Respiratory Failure and Altered Mental
Status

• Alicia M. Mohr, MD
• Surgical Fundamentals Session 2
• July 21, 2006

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
(No Transcript)
4
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 gt 90
Not intubated
intubate
ASSESS PATIENT
Hemodynamically stable
Step 2
Check CXR, ABG
Pulse Oximetry
Sa02 lt 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
5
History
?
6
History

• Cant catch my breath
• Lightedheadedness
• Usually acute onset
• Minimal symptoms

7
Physical Exam Findings
?
8
Physical Exam Findings

• Tachypnea
• Dyspnea
• Retractions
• Nasal flaring
• Grunting
• Diaphoresis
• Tachycardia
• Hypertension

• Altered mental status
• Confusion
• Agitation
• Restlessness
• Somnolence
• Cyanosis (need 5mg/dl of unoxygenated blood)

9
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.

10
A - Airway B - Breathing C - Circulation
Assess, change, reassess
11
Case Study 1

• Signs of respiratory distress
• Nasal flaring
• Sternal retractions
• Tripoding
• Use of accessory muscles
• Tachypnea
• Cyanotic
• Anxiety, restlessness

12
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

?
13
Indications for Intubation
?
14
Indications for Intubation

• Airway protection
• Loss of gag reflex, GCS lt8
• Massive facial trauma
• 2. Failure to ventilate
• Increased work of breathing
• PaCO2 gt 55 mm Hg
• 3. Failure to oxygenate
• Hypoxemia or PaO2 lt 60 mm Hg
• Severe metabolic acidosis or shock
• Need for bronchopulmonary toilet

15
The Decision to Intubate
16
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!

17
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
18
(No Transcript)
19
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

?
20
(No Transcript)
21
Pathophysiology of Respiratory Failure

• Due to mismatch of ventilation and perfusion in
  lung units

22
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 gt 90
Not intubated
intubate
ASSESS PATIENT
Hemodynamically stable
Step 2
Check CXR, ABG
Pulse Oximetry
Sa02 lt 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
23
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

24
Differential Diagnosis
?
25
Differential Diagnosis

• Pneumothorax
• Pneumonia
• Lobar collapse
• Pulmonary embolus

26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
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.

33
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 gt 90
Not intubated
intubate
ASSESS PATIENT
Hemodynamically stable
Check CXR, ABG
Pulse Oximetry
Sa02 lt 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
34
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.

?
35
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?

36
Altered Mental Status

• Five major causes
• Metabolic derangement
• Drug toxicity/overdose/withdrawal
• Infectious
• Strutural abnormality
• Psychiatric

37
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

38
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

39
Altered Mental Status

• Infectious cause
• Assess for post operative sepsis
• Assess risk of meningitis
• Assess need for CT

40
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

41
Altered Mental Status
42
Altered Mental Status

• Psychiatric cause
• Assess for hallucinations
• Assess for delusions
• Mini-neuro exam

43
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 gt 90
Not intubated
intubate
ASSESS PATIENT
Hemodynamically stable
Step 2
Check CXR, ABG
Pulse Oximetry
Sa02 lt 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
44
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.

45
Differential Diagnosis
?
46
Differential Diagnosis

• Pneumonia
• Lobar collapse
• Pulmonary embolus
• Aspiration
• Sepsis
• Pulmonary edema
• Congestive heart failure
• Myocardial infarction

47
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

48
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 MM?

49
Criteria for ICU assessment Threatened airway
Respiratory arrest Respiratory rate gt30 or lt8
breaths / min Oxygen saturation lt90 on gt50
oxygen Cardiac arrest Pulse rate lt60 or gt140
beats / min Systolic blood pressure lt 90 mmHg
Sudden fall in level of consciousness Repeated
or prolonged seizures Rising arterial carbon
dioxide tension with respiratory acidosis
50
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.

?
51
Differential Diagnosis
?
52
Differential Diagnosis

• Pneumonia
• Lobar collapse
• Pneumothorax
• Pulmonary embolus
• Aspiration
• Sepsis
• Pulmonary edema
• Mucous plugging
• Bronchospasm
• ETT is dislodged

53
What do you do?

• Take patient off the ventilator and hand bag
• Rule out ventilator problem
• Assess degree of airway resistance
• Listen to the lungs
• Rule out pneumothorax, fluid overload,
  bronchospasm
• Order a CXR, ABG
• ABG will be bad, but will assess acidosis, and
  ventilation
• CXR will assess ETT placement, lobar collapse,
  effusion, pneumonia, etc.
• Does patient require bronchoscopy?
• Pass a suction catheter
• Rule out an occluded, dislodged ETT and assess
  secretions
• Give a bronchodilator
• Cant hurt! May loosen secretions
• If chest tubes in place, make sure on suction and
  assess for air leak
• Adjust ventilator to compensate worsening
  respiratory failure

54
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 gt 90
Not intubated
intubate
ASSESS PATIENT
Hemodynamically stable
Step 2
Check CXR, ABG
Pulse Oximetry
Sa02 lt 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
55
(No Transcript)
56
ARDS

• A patient must meet all of the following
• Acute onset of respiratory symptoms
• CXR with bilateral infiltrates
• No evidence of left heart failure
• PaO2/FiO2 lt 200mm Hg (regardless of PEEP)
• American-European Consensus Conference on ARDS
  (Am J Resp Crit Care Med 149818, 1994)
• The following are implied
• Previously normal lungs
• Decreased lung compliance
• Increased shunting
• Hypoxemic respiratory failure

57
?
58
(No Transcript)