A patient arrives in the emergency department following a motor vehicle accident in which the patient sustained a deceleration chest injury

Question

The patient was intubated in the field for airway protection. Physical assessment reveals that the patient is spontaneously breathing at a rate of 16 breaths/min, and breath sounds reveal bibasilar fine crackles at end inspiration. A second arterial blood gas was drawn while the patient was re-ceiving 100% oxygen from an air entrainment large volume nebulizer.
Parameter 9:35 PM 10:10 PM
pH 7.53 7.50
PaCO2 (mm Hg) 27 30
PaO2 (mm Hg) 48 56
SaO2 (%) 90 91
HCO3 (mEq/L) 24 24
Supplemental oxygen Room air 100% Bland aerosol
The most appropriate recommendation for this patient is which of the following?
a. Continuous positive airway pressure (CPAP) with supplemental oxygen
b. Pressure-controlled inverse ratio ventila-tion (PCIRV) with positive end-expiratory pressure (PEEP) and sedation
c. Volume-controlled continuous mandatory ventilation (VC-CMV)
d. Airway pressure release ventilation (APRV)

Answer 1

ANS: A
Both the assessment and blood gas results reveal that the patient is spontaneously breathing. However, it appears that the patient is suffering from "air hunger." The blood gases reveal that the patient has refractory hypoxemia. With this information, the most appropriate recommenda-tion would be to place the patient on continuous positive airway pressure (CPAP) with supple-mental oxygen to improve the refractory hypoxemia by opening up atelectatic areas and main-taining them open. Since the patient is breathing spontaneously, mechanical ventilator breaths are not necessary.