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
meningismus.
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:
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
meningismus.
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
(1835-1910)
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
(1835-1910)
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