BP: 156/66. HR: 81. RR: 22. Temp: 97 POx: 100% on O2 at 2 L/min.
Appearance: Lethargy; responsive to pain.
Eyes: Mild left conjunctival injection.
Neck: No JVD
CVS: Normal heart rate and rhythm; heart sounds normal; pulses normal. Dialysis catheter present in L chest wall.
Respiratory: Mild respiratory distress; shallow respirations; mild end-expiratory wheezes.
Abdomen: Soft and nontender.
Skin: Skin warm and dry; normal skin color; no rash; normal skin turgor.
Extremities: RLE BKA; no signficant LE edema; RUE with mild edema.
Neuro: Generalized weakness.
ECG: NSR, normal axis, prolonged PR, QRS 140ms, Peaked T
Bedside sonogram: A lines present, no B lines, good contractility, minimally collapsible IVC
I know that you all know how to treat severe hyperkalemia. Calcium gluconate 2g, dextrose 50g/insulin 10u, and albuterol 20mg were given. 2 hours after arrival, hemodialysis was started in the ED. Ipratroprium 0.5mg, dexamethasone 12mg, and broad-spectrum antibiotics were also given. A critical care medicine consult was sought, and the fellow insisted on intubation and mechanical ventilation. She also reported that there were no ICU beds available and asked for the obligatory ABG.
1) Will doing the requested ABG assist in the immediate management of this patient? If so, how?
2) Would you follow the recommendations of the “consult” and intubate this patient? If so, which ventilation settings would you use? If not, then what alternative therapies would you employ (be as specific as possible)?
3) What type of respiratory insufficiency is present (Type I or Type 2)? What are possible etiologies of this patient’s respiratory insufficiency?
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