While on-call in the hospital, you are called to evaluate a 74-year-old female for SOB and increasing oxygen requirements. She does not have a cough. The patient was admitted yesterday with multiple leg fractures after a motor vehicle accident. She has been on strict bed rest since admission while a plan is made for surgical repair. She has mild chest pain and feels short of breath. Past medical history is significant for HFpEF and COPD. She is adherent with her medications, which include tiotropium, furosemide, and carvedilol. Temperature 100.0°F, BP 116/74 mm Hg, pulse 120, RR 24, oxygen saturation 91% on 4 L of oxygen via nasal cannula. General examination reveals a patient who is alert and oriented to name and year but not to place. Mental status on admission was normal and she has no history of neurocognitive disorder. Lung examination reveals good air movement throughout with no wheezing, crackles, or consolidation. JVP is not elevated. There are scattered petechiae on the upper chest. Bilateral lower extremities have symmetric 1+ edema without calf tenderness. CT chest shows scattered ground-glass opacities without consolidation, no segmental or subsegmental emboli, and no effusions. What is the appropriate next step in management?Ask StudybuddyGroup of answer choicesFurosemideReduction of fractureIV heparinLevofloxacinAlbuterol
Question
While on-call in the hospital, you are called to evaluate a 74-year-old female for SOB and increasing oxygen requirements. She does not have a cough. The patient was admitted yesterday with multiple leg fractures after a motor vehicle accident. She has been on strict bed rest since admission while a plan is made for surgical repair. She has mild chest pain and feels short of breath. Past medical history is significant for HFpEF and COPD. She is adherent with her medications, which include tiotropium, furosemide, and carvedilol. Temperature 100.0°F, BP 116/74 mm Hg, pulse 120, RR 24, oxygen saturation 91% on 4 L of oxygen via nasal cannula. General examination reveals a patient who is alert and oriented to name and year but not to place. Mental status on admission was normal and she has no history of neurocognitive disorder. Lung examination reveals good air movement throughout with no wheezing, crackles, or consolidation. JVP is not elevated. There are scattered petechiae on the upper chest. Bilateral lower extremities have symmetric 1+ edema without calf tenderness. CT chest shows scattered ground-glass opacities without consolidation, no segmental or subsegmental emboli, and no effusions. What is the appropriate next step in management?Ask StudybuddyGroup of answer choicesFurosemideReduction of fractureIV heparinLevofloxacinAlbuterol
Solution
The patient's presentation is suggestive of acute respiratory distress syndrome (ARDS), which is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. ARDS is a common complication in patients with severe trauma, such as this patient who had a motor vehicle accident. The most common findings on chest CT in ARDS are bilateral ground-glass opacities, as seen in this patient.
Given the patient's recent trauma, strict bed rest, and new petechiae (which may suggest a coagulopathy), the most likely trigger for ARDS in this case is fat embolism syndrome. Fat embolism syndrome is a rare but serious complication of long bone fractures, in which fat globules are released into the circulation and cause systemic symptoms, including respiratory distress, altered mental status, and petechiae.
The mainstay of treatment for ARDS, regardless of the underlying cause, is supportive care with mechanical ventilation. Therefore, the appropriate next step in management for this patient is to start her on IV heparin. This will help to prevent further clot formation and embolization, which could worsen her respiratory status.
Furosemide, a diuretic, would not be helpful in this case as the patient's respiratory distress is not due to fluid overload. Reduction of fracture would be important in the overall management
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