Brief Background: CG is a 16 y.o.

high school student who was brought to the ER 2 hours ago from an

afterschool activity because she could not breathe. She is a known asthmatic.
Assessment Problem Statement

Impaired oxygenation RT Vitals: T 99.0, P 132, R Severely constricted 28 airways (and alveolar BP 120/68 %sat 88 on hypoventilation) 3L/min O2 AEB Observations: Elevated PaCO2 Sitting upright Use of abd. muscles in tripod position. with exhalation Using abd. Refractory hypoxia

Last admit for resp. failure! 6 mos. ago

muscles to exhale, SCM and traps to breathe in. 3-4 syllable dyspnea Dry, nonproductive, tight cough
Examination:

Distant BS with prolonged exp. phase (3:1 E:I) and abundant high

~~~~~~~~~~~~~~~ Severely impaired oxygenation and CO2 elimination RT Worsening airway restriction AEB Silent chest Deterioration of VS, ABGs, CO2 narcosis

Collaborative actions: Within 8 O2 4L/min per nasal hours prongs PaCO2 will Start IV stat begin trend replacement fluids (see toward fluid and electrolytes) normal and Methylprednisolone %sat will be 62.5 mg IV q6h above 95 on Albuterol 5 mg/hour 2L/min O2 continuous nebulization Magnesium sulfate 2G IV once Independent actions:

Goals

Actions

Evaluation

1500 hrs: 1. Patient increasingly somnolent 2. PaCO2 now 65, pH now 7.24 3. Wheezes almost inaudible
Conclusion:

Continuous cardiac monitoring VS & chest auscultation q1h and prn Over-bed table to support patient in tripod position

1. Treatments not helping. 2. Pt. is not moving air. 3. Respiratory failure.

Reformulation:

1. Facilitate intubation and

pitched wheezes throughout

Supporting Labs:

Chemistries Na+ 147, K+ 4.2, Cl- 115, HCO3- 18, BUN 28, Creat 1.8 Glucose 120 ABGs PaO2 88 (4L/min) PaCO2 55, pH 7.28 %sat 94 Drug screen Theophylline level 5

beginning mechanical ventilation. 2. Inform parents, make sure they can follow transport to Peds ICU

Diagnostics:

CXR: Flattened diaphragms, hyperinflated lung fields