A 42 year-old male is admitted to the ER after being discovered unconscious at home. His wife states he was healthy when she left for work at 8:00 that morning. When she returned at 4:30 she found him unresponsive in a chair in front of the TV. He was breathing rapidly and deeply and was bluish in color. The ambulance was called and he was transported to the ED on a non-rebreathing mask at 15 lpm. The SpO₂ during transport was 78%.

You arrive in the ER to assist in the evaluation and treatment of this individual. You are provided the following Blood gas/pH Data

pH 7.25

PaCO2 41 mmHg

PaO2 62 mmHg

HCO3- 18 mEq/L

SaO2 87%

What should be done for this person?

Additional Data Requested

CXR pending

FIO2 0.85

Patient was intubated and ventilated with the following settings for 22 minutes prior to the sampling of arterial blood

Set rate 12 BPM

Actual rate 26 BPM

Vt 600 ml

Ti 1.2 sec

PEEP 12 cmH2O

Blood Glucose 88 mg/dl

BP 128/62 mmHg

HR 164 / min

Cardiac Output No Swan Ganz in place

First suggestion was to increase FIO2 to 1.0

Questions that are important to consider are possibility of oxygen toxicity from the high F_IO₂ versus barotrauma from raising the PEEP.

How should we decide whether to increase PEEP, F_IO₂ or both in such a situation?

Ventilator graphic information was requested

Time

Press

Time

Vol

10 20

Pressure

Is it better to increase F_IO₂ or PEEP at this time? Explain your rationale for the increase.

Are there other changes you would now make to the ventilator setting?

What would they be and why would you make them?

The Chest X-ray is brought in by the Technician and placed on the viewer.

What does this tell you about the patient problem? How do you know this? What do you do now?