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Dr Santosh Kondekar, MD DCH FCPS DNB
from:Seth GS Medical college & KEM Hospital Mumbai, India
http://kempeds.learn.to

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Doctor! The Patient's Blood Pressure is Falling!

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BACKGROUND A 67-year-old woman with a history of end-stage chronic obstructive pulmonary disease (COPD) is admitted to the hospital because of severe respiratory distress. She requires intubation in the emergency department because of respiratory acidosis. The patient's mechanical ventilator setting is in assist control (AC) mode, with the respiratory rate at 16 breaths per minute, the tidal volume at 500 mL/kg, and the fraction of inspired oxygen (FIO2) at 80%. Her vital signs are temperature, 100.4°F (38°C); heart rate, 104 beats per minute (bpm); pulse oximetry reading, 90%; and blood pressure, 130 mm Hg systolic, 80 mm Hg diastolic. Two hours later, the nurse pages you because the patient's blood pressure had decreased to 75 mm Hg systolic, 50 mm Hg diastolic. Physical examination reveals diffuse and bilateral wheezing with distinctive heart sounds. A frontal chest radiograph (A) is obtained. What should be performed immediately to reverse the hypotension? a. Starting a dopamine infusion b. Placing a chest tube c. Decreasing the ventilator rate d. Increasing the tidal volume Hint Chest radiograph A reveals hyperinflated lung fields with the endotracheal (ET) tube properly positioned. Author: Mounir Fertikh, MD, and Shaikh Naushad, MD Department of Medicine, Mercy Fitzgerald Hospital eMedicine Editor: Sat Sharma, MD University of Manitoba
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