ADMITTING HISTORY AND PHYSICAL EXAMINATION

ADMITTING HISTORY AND PHYSICAL EXAMINATION

A 17-year-old male, on his way home from high school, was severely beaten when he accidently came upon a rival gang fight in Chicago, Illinois. He was knocked unconscious with a baseball bat and viscously kicked in his head and chest by four different boys. He was brought into the emergency department unconscious and breathing in a rapid and gasping-like fashion. Both his eyes were swollen shut and he had multiple cuts and contusions across his face, neck, and anterior portions of his chest. His nose was broken, and he was missing three of his front teeth. Even though he was on a non-rebreathing mask, his skin appeared cyanotic.

His vital signs were a blood pressure of 155/110, heart rate of 135, and respiratory rate of 35. His temperature was 98.6(F. Auscultation revealed bilateral bronchial breath sounds. His arterial blood gases (on a 100% O2 non-rebreather mask) were pH 7.56, PaCO2 24, HCO3, 21, PaO2 68, SaO2 94%. A chest radiograph showed an increased opacity caused by atelectasis and consolidation throughout both lungs. The patient was difficult to intubate—because of upper airway swelling—and the physician elected to perform a tracheotomy in the emergency room. The patient was then transferred to ICU and placed on a mechanical ventilator. Concerned about the development of acute respiratory distress syndrome (ARDS), the physician asked for a respiratory evaluation and mechanical ventilation treatment plan.

Figure: Admission chest radiograph in a 17-year-old male with severe head and chest trauma. Note the air bronchograms suggesting wide spread alveolar consolidation

Initially, the respiratory therapist started the patient on the following ventilator setting: Mode—pressure control; frequency—15 breaths/min; PIP to maintain tidal volume of 4-6 mL/kg (based on the patient’s predicted body weight of 135 lb); positive-end expiratory pressure 10 cmH2O, and an FIO2: 0.6. Assured that the patient’s respiratory status was secure, the respiratory therapist proceeded to conduct a complete evaluation and treatment plan.

Based on the above information, how would you SOAP this patient? (SOAP 1)