Clinical Case 027: tachypnoea, tachycardia and tuckered out…

This was my night shift this week.  One of those situations where you know you have to do something quick – but what?  I am going to leave it open for comment at the crucial decision point and ask for your comments – then later this week I will tell you what I did and what happened!

The Ambos roll in with a 67 yo man in severe respiratory distress – sweating, tripod posture, gasping for air and looking a bit blue around the lips.  “Acute exacerbation of COPD” they handover – so off to the “ICU room”.  I did a quick exam – quiet chest, a few faint wheezes, nicotine-stained beard.  Radial pulse is thready – barely palpable, but the chap is able to answer questions with quick “yes” or “no” between gasps.  His skin looks mottled. He admits to ’emphysema’ and has been unwell for a few days. However tonight he became very SOB over the last few hours.  At this point I was happy with – exacerbation of COPD – as a diagnosis.

I ask for the BiPAP machine and we hook him up to the monitors.  I am a bit worried about his BP with NIV so I try and get a palp BP – no able, too weak at the radial… then the monitor goes on – obs are:  pulse rate =  215 /min, narrow complex rhythm, SpO2 unrecordable, BP unrecordable, RR = 45/min, T = 37.5.

This is not good.   A quick scan through his old chart reveals another surprise – his man has been followed by the Cardiologists for aortic stenosis – his last ECHO was 6 months ago and showed severe stenosis with a valve area of 1 cm2.  He was declined for valve repair on the basis of his severe lung disease.

A quick venous gas shows: pH = 7.08, pCO2 = 101, HCO3 = 28, Hb = 186 lactate = 5.7.  Not good…

So in summary:

  • 67 yo chap with acute-on-chronic COPD – currently severe hypercarbic respiratory failure
  • Supraventricular tachyarrythmia – probably AF @ 215/min.  That LV is getting a work out
  • Severe aortic stenosis
  • NO previously documented end-of-life discussion or NFR order etc
  • Currently tolerating BiPAP OK and appears alert though very scared

So here are my questions for you – and I am not sure there are ideal answers – so let me know:

  1. What differential diagnoses might you consider?  Any unifying thoughts
  2. What are you going to do bout his tachycardia?  What interventions will help, but not kill him in the process?
  3. Where and how would you discuss the role of intubation vs. palliation in this scenario?

OK, don’t be shy.  What would you do?

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