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

4. History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Chest X-ray Lab Electrolytes Arterial Blood Gass Pulse Oximetry Sa0 2 > 90% Sa0 2 < 90% Remains agitated and risk for withdrawal (alcohol +/or drug) May sedate with Short-acting benzodiazepine or haldol Step 1 Assess Airway Step 2 Step 3 Assess Circulation Intubated Not intubated ETT good position Check CXR (go to step 2) Re-intubate intubate Hemodynamically stable Assess Breathing Hemodynamically unstable with  breath sounds Check CXR, ABG Tube thoracostomy Pulses absentACLS protocol Pulses presentAssess cardiac status- ie. arrythmias Labs & ABG normal ETT dislodged Mini-neuro exam Review chart for medications Consider need for CTH Call for Altered Mental Status Desaturation or Respiratory distress ASSESS PATIENT

5. History

6. Can’t catch my breath Lightedheadedness Usually acute onset Minimal symptoms

7. Physical Exam Findings

8. 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 37.3 o, 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 Oxygen delivery to tissues Carbon dioxide removal from tissues 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 PaCO 2 28 mmHg PaO 2 72 mmHg CXR shows mild left lower lobe atelectasis

13. Indications for Intubation

14. 1.Airway protection Loss of gag reflex, GCS <8 Massive facial trauma 2. Failure to ventilate Increased work of breathing PaCO2 > 55 mm Hg 3. Failure to oxygenate Hypoxemia or PaO2 < 60 mm Hg Severe metabolic acidosis or shock Need for bronchopulmonary toilet

16. 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! Indications for Intubation

17. Establish IV Preoxygenate patient Administer etomidate 0.3 mg/kg IV Administer succinylcholine 1.5 mg/kg IV Apply cricoid pressure INTUBATE Auscultate bilaterally to verify tube placement Use CO 2 detector to assure tube placement Secure endotracheal tube Rapid Sequence Intubation Do not release cricoid pressure until cuff inflated and tube placement verified CAVEAT: For most emergent intubations medications are not required or not available!

19. Case Study #1 His CBC and lytes are normal ABG pH 7.45 PaCO 2 28 mmHg PaO 2 72 mmHg CXR shows mild left lower lobe atelectasis

21. Pathophysiology of Respiratory Failure Due to mismatch of ventilation and perfusion in lung units

22. History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Chest X-ray Lab Electrolytes Arterial Blood Gass Pulse Oximetry Sa0 2 > 90% Sa0 2 < 90% Remains agitated and risk for withdrawal (alcohol +/or drug) May sedate with Short-acting benzodiazepine or haldol Step 1 Assess Airway Step 2 Step 3 Assess Circulation Intubated Not intubated ETT good position Check CXR (go to step 2) Re-intubate intubate Hemodynamically stable Assess Breathing Hemodynamically unstable with  breath sounds Check CXR, ABG Tube thoracostomy Pulses absentACLS protocol Pulses presentAssess cardiac status- ie. arrythmias Labs & ABG normal ETT dislodged Mini-neuro exam Review chart for medications Consider need for CTH Call for Altered Mental Status Desaturation or Respiratory distress ASSESS PATIENT

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 37.1 o, his HR is 95, RR 30 and BP 120/70. His saturation on room air is 85%

24. Differential Diagnosis

25. Pneumothorax Pneumonia Lobar collapse Pulmonary embolus

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. History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Chest X-ray Lab Electrolytes Arterial Blood Gass Pulse Oximetry Sa0 2 > 90% Sa0 2 < 90% Remains agitated and risk for withdrawal (alcohol +/or drug) May sedate with Short-acting benzodiazepine or haldol Step 1 Assess Airway Step 3 Assess Circulation Intubated Not intubated ETT good position Check CXR (go to step 2) Re-intubate intubate Hemodynamically stable Step 2 Assess Breathing Hemodynamically unstable with  breath sounds Check CXR, ABG Tube thoracostomy Pulses absentACLS protocol Pulses presentAssess cardiac status- ie. arrythmias Labs & ABG normal ETT dislodged Mini-neuro exam Review chart for medications Consider need for CTH Call for Altered Mental Status Desaturation or Respiratory distress ASSESS PATIENT

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

43. History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Chest X-ray Lab Electrolytes Arterial Blood Gass Pulse Oximetry Sa0 2 > 90% Sa0 2 < 90% Remains agitated and risk for withdrawal (alcohol +/or drug) May sedate with Short-acting benzodiazepine or haldol Step 1 Assess Airway Step 2 Step 3 Assess Circulation Intubated Not intubated ETT good position Check CXR (go to step 2) Re-intubate intubate Hemodynamically stable Assess Breathing Hemodynamically unstable with  breath sounds Check CXR, ABG Tube thoracostomy Pulses absentACLS protocol Pulses presentAssess cardiac status- ie. arrythmias Labs & ABG normal ETT dislodged Mini-neuro exam Review chart for medications Consider need for CTH Call for Altered Mental Status Desaturation or Respiratory distress ASSESS PATIENT

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 100 o, 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. 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 M&M?

49. Criteria for ICU assessment Threatened airway Respiratory arrest Respiratory rate >30 or <8 breaths / min Oxygen saturation 50% oxygen Cardiac arrest Pulse rate 140 beats / min Systolic blood pressure < 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 FiO 2 50%. The nurse calls you because after the patient was turned and washed he desaturated to 70%. She has already turned the FiO 2 up to 100% and his saturation has not responded.

51. Differential Diagnosis

52. 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 »Can’t 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. History and Physical Exam Diagnosis Operation performed Co-Morbidities Age Chest X-ray Lab Electrolytes Arterial Blood Gass Pulse Oximetry Sa0 2 > 90% Sa0 2 < 90% Remains agitated and risk for withdrawal (alcohol +/or drug) May sedate with Short-acting benzodiazepine or haldol Step 1 Assess Airway Step 2 Step 3 Assess Circulation Intubated Not intubated ETT good position Check CXR (go to step 2) Re-intubate intubate Hemodynamically stable Assess Breathing Hemodynamically unstable with  breath sounds Check CXR, ABG Tube thoracostomy Pulses absentACLS protocol Pulses presentAssess cardiac status- ie. arrythmias Labs & ABG normal ETT dislodged Mini-neuro exam Review chart for medications Consider need for CTH Call for Altered Mental Status Desaturation or Respiratory distress ASSESS PATIENT

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 –PaO 2 /FiO 2 < 200mm Hg (regardless of PEEP) –American-European Consensus Conference on ARDS (Am J Resp Crit Care Med 149:818, 1994) The following are implied: –Previously normal lungs –Decreased lung compliance –Increased shunting –Hypoxemic respiratory failure