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:
- What differential diagnoses might you consider? Any unifying thoughts
- What are you going to do bout his tachycardia? What interventions will help, but not kill him in the process?
- Where and how would you discuss the role of intubation vs. palliation in this scenario?
OK, don’t be shy. What would you do?