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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Acute Respiratory Distress in the ICU
Auscultate and Check that Trachea is midline:
Diagnosis
Trachea
Displacement
Air Entry
Percussion
Other
ETT migrated
(commonly to R
mainstem
bronchus)
To L EF T (i f R
mainstem
intubation)
Decreased on L
Decreased on Left
Pneumothorax
Away from affected
lung
Decreased on
affected
side
Increased on
affected side
May have
SubQ
emphysema if
trauma induced
Collapse (mucous
plug)
Towa rd s a ffe c te d
side
Decreased on
affected
side
Decreased on
affected side
BONUS
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Gas Trapping
• Aka auto-peep or intrinsic-peep
• What is it
– Occurs when the expiratory time on the vent is shorter than the actual
time needed to fully deflate the lungs
• How to detect
– Do an end-expiratory breath hold
110
BONUS
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Gas Trapping
111
Signs and Symptoms
• Increased work of breathing
• Wheeze
• Increased chest distension
• Decreased chest expansion
• Bilateral decreased air entry
• Increased CO
2
• Increased intrathoracic pressures
– Dec venous return and
hemodynamic instability
Causes
• Machine factors
– Kinked ETT
– ETT clogged by sputum
– Patient biting on ETT
• Vent settings
– High RR
– High I:E ratio
• Patient
– Bronchospasm
– Increased RR
BONUS
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Gas Trapping
112
BONUS
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Vent changes
• Need long I:E ratio (1:4 or 1:5) (i.e. give
more time to exhale)
• Lower the resp rate
• Decrease the Vt
• Apply PEEP to counter the increased work
of breathing
• Last line measures
– Disconnect from vent and press on chest
– Heliox
– ECCOR2
– High frequency oscillation
Patient changed
• Reverse anything reversible
(bronchodilators/steroids)
• Suction ETT and make sure patent
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• Run ACLS as one would non-pregnant patient
• Detach all fetal monitors
• If it is a shockable rhythm-defibrillate!
– A delay in defibrillation decreases chance of survival
• Must move the gravid uterus off the IVC once fundus is at or above
umbilicus (20 weeks)
– IVC compression reduced SV and COàManual left lateral uterine displacement
– IV must be above the diaphragm
– If getting IV Mg, stop and give calcium chloride or gluconate
• Focus on early intubation as ++hypoxia (either ETT or supraglottic devise)
• Resuscitation should not be overshadowed by postmortem cesarean delivery
– PMCD should be considered in the later half of pregnancy
– Consider PMCD at 5 minutes of resuscitation
BONUS
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Maternal cardiac arrest
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Hypothermia
114
Brown D et al., N Engl J Med 2012; 367:19301938
BONUS
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Hypothermia
Brown D et al., N Engl J Med 2012; 367:1930-1938
BONUS
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BONUS
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• Van Baarle N Engl J Med 2023; 388:1956-1965
• Pts with Plt 10-50 in ICU or Hematology ward requiring CVC
• Intervention: Prophylactic plt transfusion before CVC insertion vs
no transfusion
• Non-inferiority study – outcome catheter related bleeding
• Withholding plt transfusion before CVC insertion if plt 10-50 was
NOT non-inferior (i.e. more catheter related bleeding in the
control group)
Central line placement and Platelets
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MCQ #1 – 2023
A 70 year old male presents with a one day history of fevers, chills, and right flank pain. He was
previously well, and has a past medical history of hypertension, dyslipidemia and BPH.
On exam: he is drowsy, but rousable, GCS 14, confused to date. His BP is 79/40 (MAP 53), HR 120
sinus tach, resp rate 18, satting 99% on room air. His physical exam is notable for costovertebral
angle tenderness on the right.
Labs: WBC 18, plt 475, Hgb 118, Cr is elevated to 365 (baseline 90), lactate 5, VBG: 7.25/25/12.
Urinalysis is positive for leukocytes and nitrites. All else is normal. Blood cultures are pending.
Imaging: An abdo X-ray was unremarkable and a CT abdo is pending.
The patient has been given 2.5L of balanced crystalloid and was started on empiric antibiotics. You
perform a bedside ultrasound, which shows a grade I LV (by visual estimation), no pericardial
effusion, no B-lines, and a non-collapsible IVC (on inspiration) measuring 2.5 cm.
• Which of the following is the next best course of treatment
a) Give 2L of NS
b) Give 500 cc of 5% albumin
c) Start norepinephrine infusion
d) Start dopamine infusion
117
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MCQ #1
• Which of the following is the next best course of treatment
a) Give 2L of NS – based on your dynamic measurements of fluid responsiveness using
bedside US, this patient is likely fluid replete and would not benefit from additional
boluses.
patient required additional fluid, would recommend additional balanced crystalloid
bolus.
c) Start norepinephrine infusion – given the IVC is non-collapsible and measuring
greater than 2cm, patient would likely not respond to further fluid boluses and
should start on vasopressors due to the presence of shock.
d) Start dopamine infusion – not a first line vasopressor, norepinephrine would be the
appropriate choice.
118
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