Case of the Week
A 49-year-old man with a history of smoking and hypertension complains of acute
onset severe headache and neck pain since last night.  On further investigation, his symptoms began after an all-night revelry fueled by intranasal cocaine.

On examination, HR 99 BP 132/90 RR 22 SpO2 95% RA

He is alert and mildly agitated, but attends to your questioning.  He has no cranial nerve deficits, and his neurologic examination is normal.  His head-to-toe
examination is otherwise non-contributory except for what appears to be mild

CT of his head shows subarachnoid hemorrhage.

You give nimodipine, consider a prophylactic antiepileptic, and arrange for a 
neurosurgical consult while providing good supportive care.

Shortly after, your patient becomes drowsy and confused and begins to have increased work of breathing with a pulse oximetry reading of 92% on ambient air.  A stat chest xray is performed:
The tempo and extent of his mental status changes and hypoxia prompt you to place a definitive airway.  Regarding optimization of his oxygenation and ventilation status, which of the following may be beneficial:

    A. Increase positive end  expiratory pressure (PEEP) slowly
    B. Provide gentle diuresis
    C. Place patient in the prone position
    D. Slow respiratory rate to avoid high peak pressures

In the meantime, a quote –

“A thing long expected takes the form of the unexpected when at last it comes."

– Samuel Langhorne Clemens – better known as Mark Twain – American author 


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