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DB, a 43-year-old-male, was admitted to the
emergency department following an assault during which he
was beaten with an aluminum baseball bat. He sustained injuries
to the head, chest, and abdomen, but did not lose consciousness.
Upon arrival at the ED, DB scored 13 on
the Glasgow Coma Scale. His airway was patent and his breath
sounds were clear and equal bilaterally. Heart rate was
92, respiratory rate was 20, blood pressure was 144/67,
temperature was 37.1 C, and SpO2 on room air was 100%.
Initial physical examination revealed bruising
and swelling around the left eye orbit and an opacified
iris with no vision of the same eye. In addition, he complained
of abdominal and chest pain, which correlated clinically
with bruising and swelling of the same area. Chest radiograph
and c-spine images did not show any signs of trauma. Following
the initial exam, DB scored 15 on the GCS. However, he did
exhibit gross hematuria, which prompted an irrigation of
his bladder and CT scans of the head and abdomen.
DB was admitted to the hospital. CT scan suggested a spleen
laceration, a kidney contusion, and splenic pseudoaneurysm,
which would eventually require dialysis. Not long after
admission, he experienced a large hypotensive event. Four
units of blood were required to stabilize. Ativan and morphine
were ordered for pain and anxiety.
Two days later, the patient's chest radiograph showed right
upper lobe collapse and bilateral infiltrates. This and
his physical assessment suggested the development of adult
respiratory distress syndrome. The decision was made to
place the patient on ventilatory support via the Puritan-Bennett
7200 ventilator, with the following settings:
The patient did not respond well to mechanical ventilation,
with repeated episodes of refractory hypoxemia and general
agitation. Therefore, he was given neuromuscular blocking
agent and the ventilator settings were changed to:
Within three days of initiation of mechanical ventilation,
the PEEP level was increased, in gradual increments, to
a maximum of 22.5 cmH2O, with an FiO2 of 0.80, in order
to maintain a PaO2 of 90 mmHg and a SaO2 of 92%.
Over the next several days, the patient began to improve
and the PEEP was eventually reduced to +5 and the FiO2 decreased
to .40. Arterial blood gases drawn on these settings (tidal
volume 420 mL, rate 28) were:
A tracheostomy was performed after 26 days
of ventilatory support. At this time, morphine and Ativan
were reduced and the patient became more alert. In addition,
injuries to his kidney and spleen appeared to be healing nicely
and there was hope that he would successfully wean from ventilatory
support and undergo rehabilitation.
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