Case No. 29

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Case No. 29

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Chief Complaint:

Shortness of breath, wheezing

Published: May 26, 2017
Case No. 29
Author: ppwei
CASE SCENARIO

A 24 year old male presents to the emergency department with shortness of breath and wheezing. He reports that he has a history of asthma and has been hospitalized multiple times and previously has been admitted to the ICU. His initial vital signs are T: 37.4, HR: 115, BP: 134/76, RR: 28, SpO2: 92%. The patient is given albuterol, ipratropium, steroids, and magnesium. He shows minimum improvement and starts to display signs of fatigue and lethargy. The patient is given ketamine and rocuronium and subsequently intubated and connected to a ventilator. Within one minute, the patient’s BP droops to 90/52. The patient has equal bilateral chest rise and breath sounds on auscultation and the trachea appears midline.

QUESTION

What is the best next step in management?

Start intravenous fluid and antibiotics to cover presumed sepsis from a respiratory source
Withdraw the endotracheal tube 2-3cm for presumed right mainstem endobronchial intubation
Disconnect the endotracheal tube from the ventilator and apply gentle pressure over the chest to facilitate exhalation
Order a stat chest x-ray and bedside echocardiogram to rule out pneumothorax and pericardial tamponade
Observe the patient and do nothing as the blood pressure will improve once the intubation medications have worn off